HomeMy Public PortalAbout4901 FIESTA AVE_Mechanical__ 1
WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89
76A364C LIMEGREEN,�
I hereby.aff�'rri that I,have a certificate of consent to self insure, APPLICATION FOR PERMIT
or arcertificat� of Worker'9 Compensation Insurance, or a certified HEATING-VENTILATING-;AIR CONDITIONING
copy thereof(Seca 3,800 Lab. C.) "
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
r_1 Certified copy is hereby furnished.
ILDING
❑ Certified co Is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUDRESS
department. y p (PRINT OR TYPE ONLY) 11
ADDRESS'
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the MAPEBOOKPARCEL 02
Q
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM PAGFDJ
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 I BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU !
' APPROVALS DATE INSPECTOR'S IGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH —3—
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT—
(commencing
NIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL T
Professions Code,and my license is in full force and effect.
License Number 0444&-Lic.Class
Contractor,1tI>��A `eI�td Date U
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE / 0
Date: 2'�17r 3 TOTAL FEE �J, s5 Wa
Signature A CD
NER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME ,• "
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS ACCT.a
EJ I, as owner of the property, or my employees with wages +
as their sole compensation, will do the work and the CITY TEL.NO. 30 50.,5
structure is not intended or offered for sale (Section 7044, ITEMS
Business and Professions Code). OWNER
M O • _.
❑ VD D'v 1, as owner of the property, am exclusively contracting TOT rf✓g' 55
MAIL 0� 1 .IL a�+ m =a-_s
with licensed contractors to construct the project (Sec- ADDRESS c cc
V CHECK. £�
tion 7044, Business and Professions Code). 50.55
CITY TEL.NO. /�
CONSTRUCTION LENDING AGENCY Z �/"� CHANGE 111
I hereby affirm that there is a construction lending agency for CONTRACTOR , CHANGE
the performance of the work for which this permit Is issued 1J
(Sec.3097, Civ.C.).
- ADDRESSn t'1t�Z18 -
Lender's Name 4 rA
' J0j-0-0001 2/17/193
tt i
CITY :/� ^` NO. - • - Iii 1 Fri!li a I}I.�
Lender's Address STATE /�+_1 1 `+ILIC.
I certify that I have read this application and state that the above LICENSE NO. 401 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE