HomeMy Public PortalAbout5117 AGNES AVE_Mechanical_0 r 4 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 certified copy thereof (Sec 3800 Lab C ) 76A364C
CE 818(REV 10/81)
Policy No Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
r t
❑ Certified copy Is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING
tion department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less )
AIR HANDLING UNIT CFM
I certify that In the performance of the work for which this L � ,
permit is Issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation LOWS APPROVALS DATE INS CTOR 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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked p 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
and Professions Code and my license is in full force and effect >'
d
License Number s�e�� Lic Class , U
Contractor IV75,KS C49CONOW.te O
EJI am exempt under Sec t �
Plan check fee H
B 8P C for this reason. PERMIT ISSUING FEE �9 0 2 7 A Z
D
Signature TOTAL FEE # o io o e e 8
IP N PLAN CHECK APPLICANT it �� 0 02Q50
1 hereb at I am a ntractor s License
Law for the following reaso5 Business and NAME 00020,506
Professions Code)
I as owner of the premployees with ADDRESS 0223r-88
wages as their sole compensation will do the work and
t the structure Is not Intended or offered for sale(Section CITY TEL N
7044 Business and Professions Code) OWNER C��G
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
tion 7044 7044 Business and Professions Code) ADDRESS
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 f
(Sec 3097 Civ C )
ADDRESS
Lender s Name
Lender s Address CITYIle
11�f! TEL N �7d fD
I certifythat I have read this application and state that the STATE �6�� LIC / Jl1
PP LICENSE NO CLASS .. _
above information Is correct I agree to comply with all County
ordinances and State laws relating to building construction
and here Or reprejjpty
ves of this County to enter
upon 1 abov for Inspection pu oses SEE REVERSE FOR EXPLANATORY LANGUAGE _
Sign Vof App ant or Agent Date