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HomeMy Public PortalAbout5225 FARAGO AVE_Mechanical__ ION DECLARAT ' WORKER'S I have a certificate of consent to 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN ' 76A364C I hereby affirm that I have a certificate of consent to self insure, or a certificate of worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(SeG.3800 Lab.b.) t, Policy No. Company �' {s�(��� WkRIUNTY OF LOS ANGELES. DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the county buil ng inspe n FOR APPLICANT TO FILL IN gDDRESS department. (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE. CERTIFICATE OF EXEMP FROM PIKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed if the work involved ASSESSOR ( b.P Y the MAP BOOK ;7-/ PAGE GG� PARCEY" �6 permit is for.one hundred dollars($100)or less.) DISTRICT NO, PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensatiod•Laws. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT:If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER provisions of the Labor'Code, you must forthwith comply with such FINAL "2Z provisions or this permit shall be deemed revoked. FURNACE: FAU —GRAVITY s� LICENSED CONTRACTORS DECLARATION f FLOOR BTU J VALIDATION I hereby affirm that I arr licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is.in'full force and effect. r License Number � !2�Z Lia ClassC`!c_J Contractor Date / Ci Z , ElPlan check fee Q I am exempt under Sec. BAP.C.for this reason PERMIT ISSUING FEE <f 7S' _• _ 0 Date: TOTAL'FEE �!' ya f} ��: W Signature 7307 a PLAN CHECK APPLICANT3-''r;�"• CD OWNER-BUILDER DECLARATION _ i1 t4° Z I hereby affirm that I am exempt from the Contractor's License Law NAME , for the following reason (Section 7031.5, Business and Professions i f f �-� Code): ❑ ADDRESS vl I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ❑ I, as owner of theproperty, am exclusive) contracting Y 9 MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). k CITY TEL.iNO. CONSTRUCTION LENDING AGENCY / hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued CONTRACTOR (Sec.3097, Civ. C.). d: ADDRESS z_ n e I Lender's Name l� tiQ�l /t/+ ti ��t Iv CITY TEL.NO. ` D11 QW34 Lender's Address + STATE LIC. I certify that I have read this application and state t at the above LICENSE NO. CLASS �Z© information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned prop-t for inspecti purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE IGNATME 07 P&4CANT OR AGENT DATE ►I