HomeMy Public PortalAbout5237 FARAGO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirrp thbt I have a certificate of consent to self insure,
or a certificate of worker'$Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(9ec'3800tab; C.) ;•.
I-
PGIic�1 No. ompanyPo;QZA �L COUNTY OF LOS ANGELES I' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is.filed with the coun b ildin in/�e on FOR APPLICANT TO`FILL IN BUILDING department. y 9 (PRINT OR TYPE ONLY) ADDRESS `J Z v
Date _ZZ. Applia i. LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXE ION FR WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSORZ U
(This section need not be completed if the work involved by the MAP BOOK 4� 7�7 PAGRC_t�O PARC OO 2.
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
- 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' Compensation 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'CompensationEVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL i
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVI
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
6,51647
License Number Lic.Class -
Contractor C F_JtAA Date 0
ElI am ex pt under Sec. Plan Check fee ;( V
B.&P.C.for this reason PERMIT ISSUING FEE � F-
Date: TOTAL FEE - LU
Signature --r zi J` a a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT T i EN3, (n
_ z
I hereby affirm that I am exempt from the Contractor's License Law NAME , s"f i:-; 45
for the following reason (Section 7031.5, Business and Professions `k�. =
Code: a-�:'c�
-I, as owner of the property, or my employees with wages ADDRESS _rr ,,,� Z_;,. •?
as their sole compensation, will do the work and the CITY TEL::NO. CHtNGE ,CIO
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL !iti l ) tfT€s-,1 ''y _
with licensed contractors to construct the project (Sec- ADDRESS i
tion 7044, Business and Professions Code). =4i i:05
L`r
CONSTRUCTION LENDING AGENCY CITY TEL.s0. `
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name A &, 1,1 i��,. � L
CITY TEL.NO.
Lender's Address I�r�y L�--� try STATELIC.
I certify that I have read this application and state t at the above LICENSE NO. CLASS G-C/
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of thi County to enter upon the above-mentioned
proper f inspe purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
gSIGNAT E O LICANT OR AGENT DATE