HomeMy Public PortalAbout4818 AGNES AVE_Mechanical_5/15/1991_compressor, furnace _ v
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WORK�RSCOMPENSATIONate of consent to 76A346DPW9/89APPLICATION FOR PERMIT LIME GREEN
76A364Cy+affirm that I have a certificate of consent to self Insure torrtificate of Worker s Compensation Insurance or a certified , HEATING VENTILATING AIR CONDITIONING
copy thFreof(Sec 3800 Lab C) I ?a
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PolicyyNNo 92D ompany �DI /t011fl COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
9 No
copy is hereby furnished
BUILDING
E-1Certified copy Is filed with the county Ilding Inspection FOR APPLICANT TO FILL IN ADDRESS
department , w (PRINT OR TYPE ONLY)
Date S�S L Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY /J141
J CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST t
COMPENSATION INSURANCE ABSORPTION UNIT BTU
This section need not be completed if the work involved b 4 ASSESSOR
( P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFMw
DISTRICT NO PpOCE L
I certify that in the performance of the work for which this permit y
Is Issued I shall not employ any person in any manner so as to BOILER BTU 8
become subject to the Workers Compensation Laws p� i f
COMPRESSOR BTU
APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT 'if after making this Certificate of ROUGH S
Exemption you should become subject to the Workers Compensation a EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked / FURNACE FAU GRAVITY + i
° LICENSED CONTRACTORS DECLARATION / FLOOR BTU 000 VALIDATION '
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code and my license is in full force and effect e
T'
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License Number .�(i / Lic Class e —,;2-0 ,
' IL
K
Contractor&Offen 7ce&A) Date _r is 9/
❑ 1 am exempt under Sec Plan check fee x �' 'y A W
B&P C for this reason . L
PERMIT ISSUING FEE$ l3 -�' t OI--
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Date TOTAL FEE G D LU
Signature co
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT raL t T v Z
I hereby affirm that I am exempt from the Contractors License Law NAME
for the following reason (Section 7031 5 Business and Professions
�J i 'r
Code) ADDRESS 1.2 N L S 4L)0 -4VL r I1 t ..C
I as owner of the property or my employees with wages 1{ �r-
as their sole compensation will do the work and the CITY 2USq !7o TEL NO 9� _7 �2 if t�0_ m
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structure Is not Intended or offered for sale (Section 7044
Business and Professions Code) A.- i OWNER �� _
❑ I as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sec ADDRESS / S C)G O19L/J d � h
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY Z�S �� �7d TEL NO t��ISIa 't 1.1 c IC/_1
,�I hereby affirm that there is a construction lending agency for f _
CONTRACTOR
the performance of the work for which this permit Is issued ���p �d �' , _ i ! -i 1 �ar11J 4
(Sec 3097 Civ C) }
Lender s Name ADDRESS /� - 1 So C /1� N 0
CITY Zu S 'v STEEL NO & �~
E
Lender s Address STATE LIC
I certify that I have read this application and state that the above LICENSE NO S/oQ CLASS ��—
information is correct I agree to comply with all County ordinances I
and State laws relating to building construction and hereby authorize
repres atives of this County to enter upon the above mentioned
prop y or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE r
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SIGNATURE OF APPLICANT OR T DATE
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