HomeMy Public PortalAbout4851 AGNES AVE_Mechanical_10/5/1989 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
20 004
or a certified copy thereof (Sec 3800 Lab C ) C _ 1
20 0046 DPW 9/88 +
Policy No Company -
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
,.
❑ Certified copy is filed with the county building inspecFOR APPLICANT TO FILL IN BUILDING
tion departmentI( PRINT OR TYPE ONLY) r ADDRESS �y
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY / C
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST >
COMPENSATION INSURANCE CROSS
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PR SED s
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 0
permit is Issued I shall not employ any person in any manner r
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTORS IGNATURE
�d�1�`^v ' A lica t �p� �� COMPRESSOR BT 00 ROUGH
PP p �oa=-�-'iii- -
NOTICE TO APPLICANT If air 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 V L
with comp)y with such provisions or this permit shall be deem - !
.ed revoked i `i f FURNACE FAU '
`s C LICENSED CONTRACTORS DECLARATION FLOOR RTI Ir
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
+(commencing with Section 7000)of Division 3 of the Business ' WALL
and Professions Code and my license Is in full force and effect
License Num !2 Lic Class cZ�T 0
❑ I am exempt under ec Y x
' Plan check fee u
T B&P C for this reason n H
Date PERMIT ISSUING FEE $ Z
Signature TOTAL FEE F
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 r A1L[T.1r +
' wages as their sole compensation will do the work and ., NO 1
the structure is not intended or offered for sale(Section CITY 707 r11.�L
7044 Business and Professions Code) OWNER o ITEMS
EjI as owner of the property am exclusively contracting
+ with licensed contractors to construct the project (Sec MAIL TOTAL51-50
Tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY TY TEL NO / CHECK 91.90
1 hereby affirm that there is a construction lending agency for - t
the performance of the work for which this permit Is issued CONTRACT G CNA�IGE _ ' •CSI '
(Sec 3097 Civ C EVIL of M _
+ ~ r
Lender s Name ADDRESS f
CI_TA�A TEL OOCO-0001 10/ 5/29
Lender s Address g.
1 certifythat I have read this application and state that the ATE LIC t ��737 1 'A� .,•4[I
PP LICENSE NO � CLASS e Z�
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 �bDOVe mentioned property for ins ection urposesSEE REVERSE FOR EXPLANATORY LANGUAGEant or Agent Date _ _ ®s
c