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Home My Public Portal About5020 FIESTA AVE_Mechanical__ ION WOthat I have a certificate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LI E GREEN. 76A364C I hereby affirm 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 th&eof(Sec. 3800 Lab. C.) L1 Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy Is filed with the county buildinginspection FOR APPLICANT TO FILL IN BUILDINGf�ZA T,,� J� department. p (PRINT OR TYPE ONLY) ADDRESS SS �t ' tit Date ApplicantLOCALITY tx, NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO, PROCESSED BY I'certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to I BOILER,BTU �� become subject to the Workers' Compensation Laws. ra, r COMPRESSOR,BTU `^� t APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant _ f VENTILATION SYSTEM l NOTICE TO APPLICANT: If, after making this Certificate of ROUGH /1 Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY % c LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code, and my license is in full force and effect. _ `� 60 License Number Lic.Class L— , CL Contractor ��-�^ Date 1 I O ❑ 1 am exempt under Sec. Plan Check(@8 � B.&P.C.for this reason PERMIT ISSUING FEE$ � �p U Date: TOTAL FEE p-p d Signature 0)OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 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 - Code): ADDRESS ❑ 1, as owner of the property, or my employees with wages as-their sole compensation, will do the work and the CITY TEL.NO. , :1.1<' structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER Is V,5-0-" A ❑ 1, as owner of the property, am exclusively contracting Aa ••k MAIL r• E ) �'_'s i'1� .� _ ® ,... with licensed contractors to construct the project (Sec- ADDRESS ZO tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. yta Ej I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issuCONTRACTOR ed —T �-'�✓�^" �O Cr�t- (Sec.3097,Civ. C.). ADDRESS � J � 1 11!,,r.':,1i_;�3� if_t - Lender's Name 2 "" '' '' CITY \ L` TEL.NO. i A3 i `a» 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 and State laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned property for'ns pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT 'I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or"a c-ertified copy thereof (Sec. 3800 b. ) 76A364C f• 20-0046 DPW 9/88 P cy,No. - Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. ❑ 'Certified copy is filed with the county building inspec- FOR APPLICANT'TO FILL IN BUILDING tion department. ADDRESS ��p (PRINT OR TYPE ONLY) Date - Applicant LOCALITY or NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF'EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ( 100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM y� v 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 INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate.of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL arid Professions Code;and my license is in full force and effect. / CL License Number Lic. Class NON. d V Contractor Date OC ❑ I am exempt under Sec. O Plan check fee V BAP.C. for this reason. / H Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ti -�_• ra The structure is not intended or offered for sale (Section +.•.°e't,){ ._ a%(i 7044, Business and ProCITY TEL. NO . Professions Code). OWNER Si ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec, MAIL ADDRESS tion 7044, Business'and Professions Code). k9l1-fi _s - 00 CONSTRUCTION LENDING AGENCY CITY TEL. NO gld� I hereby affirm that there is a construction lending agency for 4•H---'C' 5 =1L= the performance of the work for which this permit is issued CONTRACTOR 5-�- to (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. N I„Ict,-i_ . 00 jf' =51 7_ Lender's Address • I certifythat I have read this application and state that the STATE �r LIC. y i PP LICENSE NO. `I`- '� CLASS �S `'�;""' �' �'1 rt'= 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agen Date ©s