HomeMy Public PortalAbout5229 FARAGO AVE_Mechanical__ WORKER'S COMPENSATION
certificate
of con
to 76A346DPW9/69 APPLICATION FOR PERMIT L ICE 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(Sec.`3800 Lab. C.) n�
Policy No. mpany K��t,t A) JC% `Q"4"cINTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. A l--f 3
❑ Certified copy is filed with the countyAbuilin inspe on FOR APPLICANT TO FILL IN BUILDING ��.Z
ydepartment. Q (PRINT OR TYPE ONLY) ADDRESS
Date L —vZ G Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM ROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR BO
MAP BOOK �� PAGE Oe PARCEL Bc�Z
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers' Compensation Laws. r
COMPRESSOR,BTU �-�-/ J
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �2
a 1115
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is isin full force and effect.
License Number �3 L , Lic.Class �_� i�jt
U95 .
CL
Contractor ate V
ElI am exempt under Sec. Plan check fee
z7 0
e.&P.C.for this reason PERMIT ISSUG FEE$
I'1V �
Date: TOTAL FEE _
Signature � D'
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT g IFI=F i� 109
�5
I hereby affirm that I am exempt from the Contractor's License Law NAME , tiy_,' ;-� a:
for the following reason (Section 7031.5, Business and Professions t_p iECK it{7 s _r
Code): ADDRESS4iGE e�i_;
El (: ?i ;; t
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 ?rl1_.
❑ I, as owner of the property, am exclusively contracting MAIL1 j y AN j;9_IF
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEDNO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
I he performance of the work for which this permit Is issued
(Sec.3097, Civ. C.).
���� � � ��,� // ADDRESS
Lender's Name�00,Cs J �( �L�a�
� CITY TEL.NO.
Lender's Address /�!�/ "�-&y Ji- STATE LIC.
I certify that I have read this application and statb that the above
LICENSE NO. CLAss
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
property for nspection poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
111�NATURJrOF AP CANT OR AGENT DATE