HomeMy Public PortalAbout4949 FIESTA AVE_Mechanical__ DECLARATI
WORKER'S COMPENSATION
certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LI E GREEN;
76A364C
I hereby aff'irm�that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Se[cc.."3`1800 Lab..�C.) GG
Policy No. �+ 50'b.Company�l" p.ntr�� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
url"Certified
ertified copy is hereby furnished.
copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY %M /� CL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE !!
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ir
CROSS ST. �y✓C Z SG
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SSOR
(This section need not be completed if the work involved by the MAPBOOKPAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSE BV
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. ^
p �e / COMPRESSOR,BTU Q60
APPROVALSf
DATE NSPECTORSIGNATURE
Date Applicant t r
VENTILATION SYSTEM
NOTIC TO APPLICANT: If, after making this Certificate of ROUGH �-
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with suchFINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR • BTU 3 a2 VALIDATION
.. I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number �� Lic.Class -
des COO.-A-
Contractor Date •R,-'�';
;•s r��:
Plan check fee
I am exempt under Sec.
BAP.C.for this reason PERMIT ISSUING FEE ._e.t.x, _ �. 0
Date: TOTAL FEE .�._• U
LU
Signature
PLAN CHECK APPLICANT - •h;-- (/�
OWNER-BUILDER DECLARATION _.;;j ;i'?3_ ,_I!_'•.
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
❑ ADDRESS -
Code): I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. AMt _
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
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
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
CITY. TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
nd State laws relating to building construction,and hereby authorize
resentativ of this unty to enter upon the above-mentioned
erty for i on rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C1NAjURE OF APPLICANT o AGE T DATE