HomeMy Public PortalAbout5030 FIESTA AVE_Mechanical__ r N,'ORKER'S COMPENSATION
certificate
of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN,
76A364C
i he;eby 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 thf(Sec. 3800 Lab.C.)
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 count buildingInspection FOR APPLICANT TO FILL IN BUILDING r Gu �`r
department. y (PRINT OR TYPE ONLY) ADDRESS J v 3 0 i s
Date Applicant NO. TYPE OF APPLIANCE OR EOUIPMENT FEE LOCALITYF4113,09& 44 / O
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST S
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK V PAGE 1910011PARCEL D�
permit is for one hundred dollars($100)or less.) EFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU 10040 ✓ 6-
APPROVALS DATE INSP CTOR'S SIG ATURE
Dale Applicant TEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL \
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
JF,
,
Contractor Date 0
ElI am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE W
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION. N DN -
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
•.�L,.a '�...L a'.,ei
Code): ADDRESSK
❑ I, as owner of the property, or my employees with wages ID `'—
as their sole compensation, will do the work and theAa CITY e—� �T Lv '� ��
structure is not intended or offered for sale (Section 7044, `y' `�= 'f—t - ' ' '
Business and Professions Code). OWNER JN
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
the performance of the work for which this permit Is issued CONTRACTOR
(Sec. 3097, Civ.C.).
i, Ail.f.
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
and State laws relating to building construction,and hereby authorize
representatives of this County.to enter upon the above-mentioned
properly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
31-9 v
NATURE OF APPL ANT O ENT DATE -