HomeMy Public PortalAbout4844 FIESTA AVE_Mechanical__ DECLARAT
WOR at I have
COMPENSATION
ate of consent to 76A364C PW9jt39 APPLICATION FOR PERMIT. LIME GREE r
I hereby affirm that I have a certlflcate 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)
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Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified copy is hereby furnished
4 BUILDING
❑ departed copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS `
(PRINT OR TYPE ONLY) 0 e y
5
LOCALITY
Date Applicant
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST l
{ `e
COMPENSATION INSURANCE a ABSORPTION UNIT BTU CROSS ST
(This section need not be completed if the work,involved by the M PEBOOK PAGE PARCEL
permit is for one hundred dollars($100)or less`) AIR HANDLING UNIT CFM
DISTRICT NO PROCESSED BY
I certify that In the performance of the work for which this permit e
Is Issued I shall not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws J
COMPRESSOR BTU 000
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Date 1 Z— 2s 2 Appllcan �� � APPROVALS DATE INSPECTOR S SIGNATURE
VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this tCertificate of _ ROUGH
Exemption you should become subject to the�Workers Compensation
provisions of the Labor Code you must forthwith comply with such EVAPORATIVE COOLER FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU — 3 S� L�J
I hereby affirm that I am licensed under'provlslons of Chapter 9 SUSPENDED UNIT(commencing with Section 7000) of DIVISIOn 3 of the Business and HEATER WALL t nom
Professions Code and my license is In full force and effect
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License Number `-� Llc Class101-
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Contractor te 1�� s 4 :,� z- '9 i i O
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❑ I am exempt under Sec Plan check fee = V
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8&P C for this reason PERMIT ISSUING,FEE$ ACCTes 0
Date TOTAL FEE 1J a 330'7 loci•7y W
Signature - -8't"-� l I
OWNER BUILDER DECLARATION KZr 1 PLAN CHECK APPLICANT wTEMS U)
Ti hereby affirm that I am exempt from the,Contractor s License Law NAME , i ITAL 10T.® 72 Z
for the following reason (Section 7031 5 Business and Professions W7Gf i 105.7:Code) ADDRESS W7Gi lr��-C ✓ 1 S
❑ I as owner of the property or my employees with wages a' r tHA{GE 1 w .ICU
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 ,
❑ =—WTJI- 12/23/C'
I as owner of the property am exclusively contracting MAIL r -�-/
with licensed contractors to construct the project (Sec ADDRESS ��o r ( `7 1 AM10�7c
tion 7044 Business and Professions Code) r
CONSTRUCTION LENDING AGENCY CITY �� t (, ` TEL NO �d F
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued CONTRACTOR y\ ` t
(Sec 3097 CIV C)
ADDRESS
Lender s Name
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CITY 4r TEL NO g�$ 33Z-PII
Lender s Address _ y
I certify that I have read this application and state that the above LICENSE NO 30 (� LIC
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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 inspection purposes L SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR�/dZ DATE
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