HomeMy Public PortalAbout4921 FIESTA AVE_Mechanical__ f
�WORKER SCOMPENSATION
ate DECLARATIof consent to 20 004676A364 DPW 9189 APPLICATION FOR PERMIT LIME GREEN
z 76A364C
I hereby afflrgl'frfat't 15ave a certificate of consent to self Insure
or a certificate of°Worker s Compensation Insurance or a certified HEATING VENTILATING AIR CONDITIONING
copy therm
eof(Sec 38Q0 La b/!
Policy No Con ' C/ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy Is hereby furnished
;4--certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS BUILDINGF
de art ant d (PRINT OR TYPE ONLY)
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Date �, Applicant Q a"�, •"�✓ LOCALITY C I
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST r
COMPENSATION INSURANCE ABSORPTIONUNITBTU CROSS ST
This section need not be completed if the work Involved ASSESSOR `
( b P Y the c � MAP BOOK 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 $
is Issued I shall not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws
r COMPRESSOR BTU
APPROVALS y DATE y INSPECTORS 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 d
provisions of the Labor Code you must forthwith comply with such " FINAL - r
provisions or this permit shall be deemed revoked _ / FURNACE FAU GRAVI
LICENSED CONTRACTORS DECLARATION ( FLOOR f BTU U 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
License Number Lic Class 0 3 * ri
���j{ j 6 AUT T ,: a
Contractor ' ` r'�-' Date l l �. - 3;�17 708.91' v
❑ Plan check fee / ,
I am exempt under Sec "' O �
B&P C for this reason t PERMIT ISSUING FEE$ ITEI`IL
_ `4 76 TJAL 78 m
Date TOTAL FEE r 727 r LLI
r " t �IEC�i �.�1
Signature _
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE J I Z
I hereby affirm that I am exempt from the Contractor s License Law NAME
for the following reason (Section 7031 5 Business and Professions t��t�ny�� �yft i C
Code)
❑ I as owner of the property or my employeesW,
wages ADDRESS e t c 1�r1it/}tU-0001 1 ri7.7-
as their sole compensation will do the-work and the e CITY TEL NO
structure is not Intended or offered for sale (Section 7044 a
Business and Professions Code) } OWNER '
❑ I as owner of the property exclusively contracting
co
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY 1 �� I `� ,TEL NO r >
I hereby affirm that there is a construction lending agency for -
the performance of the work for which this permit 4s Issuved CONTRACTOR Q, t
(Sec 3097 Civ C) ADDRESS 'w� Jr r'" LLA+�..�i� Y �
Lender s Name
s
` o CITY � � TEL NO
Lender s Address STATE -�f{r 2 ` LIC I
I certify that I have read this application and state that the above LICENSE No JJ bb ` CLAS
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 r
propert/for I s e on purpo + / SEE REVERSE FOR EXPLANATORY LANGUAGE w 4 J
2 Xi
SIGNATU APPLICAf R A E DATE t l