HomeMy Public PortalAbout4823 FIESTA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
i assure, or a certificate of Workers' Compensation Insurance, ,eA3eac HEATING - VENTILATING - AIR CONDITIONING
• or a certified copy thereof (Sec. 3800, Lab. C. CE-818(REV. 10/Bt•)
F►�li4y No. Company J I V FA_JI ACU JVb_ 2AµXE
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINGLjpj �� rl�� n 44 y}� 2
tion department. t (PRINT OR TYPE ONLY) ADDRESS r' A
Date 10 — p'� rJ LOCALITY ft
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
e CAV
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTR�NO. PR �;Y/��(This section need not be completed if the work involved bythe pehis fore hundred dollars e wor or less.)
AIR HANDLING UNIT, CFM
I certifythat in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER;BTU APPROVALS DATE IN SIGNATURE
DateApplicant COMPRESSOR, BTU OQtV ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' `y, r r
Compensation provisions of the Labor Code,,you must forth- EVAPORATIVE COOLER VA' DATION
with comply with such provisions or this-permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU q�&D 00 1
I hereby affirm that I am licensed under provisions of Chapter 9 �SUSPENDED—UNIT-
-(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect. >_
.License Number��ail`151 Lic. Class�ywp�D , U
T
Contractor wm meer Date ID-pq p(� 1
❑ 1 am exempt under Sec.
Plan check fee
B.BP.C. for this reason PERMIT ISSUING FEE $
10 _r3
Date:
Signature TOTAL FEE u ,
•e
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
p +
Law for the following reason (Section 7031.5, Business and NAME M��
Professions Code): - v
F-11, as owner of the property, or my employees withADDRESS 3 , p�[MAyFA 06- fy�.�.•�•pa
wages as their sole compensation,will do the work and !
the structure is not intended or offered for sale(Section CITY -2 L,,6A TEL. NO. -o'1(a�s"- 31-50! 30.5.1
7044, Business and Professions Code). OWNER n 1 TEMS
f S• " t'
❑ 1, as owner of the property, am exclusively contracting E L� - IIl 30 . 50
,
with licensed contractors to construct the project (Sec- MAIL O165T3
I� 2 TOTAL 0 m 50
ADDRESS O
tion 7044, Business and Professions Code). '-. ..
uI _•-
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 30.-°�l
1 herebyaffirm that there is a construction lendingagency for �O QHO . CHANGE
the performance of the work for which this permit is issued wIM ► L• 1t 3t ,E�111
P P CONTRACTOR ~
(Sec. 3097, Civ. C.).
ftZ
Lender's Name ALP-
ADDRESS �ty _� I�i1 {1+�/ 5/8
IJ 0 V
CITY fi�s� TEL. NO. _a 6069 1 AM. '9 3?
Lender's Address °`''�
STATE1 LIC.
a
I certify that I have read this application and state that the LICENSE NO. .451 CLASS
above 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
upo -he above- ntioned property for.inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature o Applicant or Agent Date