HomeMy Public PortalAbout5211 AGNES AVE_Mechanical_0 �'O�KERS COMPENSATION DECLARATION + 76A364C
hek`by„gffirir t�iat i have a certificate of consent to self CE 818 (2 80) A If�If- LL C A 8 Q O �l FOR IT E R V�'ll T
t-sure AT a certificate of Workers Compensation Insurance or n HEATING VENTILATING-Alla CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
VY� T I
Policy No i.Company I
COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ t
Certified copy is hereby furnished 1
❑ Certified copy is filed with the county,building Inspection FOR APPLICANT TO FILL IN BUILDING
department ADDRESS /
A � C
Date Applicant (PRINT OR TYPE ONLY) 17e!
!
LOCALITY
CERTIFICATE Or EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT + FEE _I_C
COMPENSATION INSURANCE NEAREST CROSS ST !�t �p d
(This section need not be completed i if the work involved ABSORPTION UNIT BTU 0
by the permit is for one hundred dollars (5100) or less) M DISTRICT NO - PROcr o BY U
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM tr
permit is issued I shall not employ any person in any manner a -5"Q /j 0
so as to become subject,to the Workers Compensation Laws BOILER BTU I—
APPROVALS'/' APPROVALS DATE INSPECTOR S SIGNATURE V
Datejj" 4Applicant �'r COMPRESSOR BTU Z��QO ROUGH ��' CL
Cn
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM ? FINAL "Z Z Z
Exemption you should become subject to the Workers "
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VAI IDATI N 7
with comply with such provisions or this permit shall be �
deemed revoked FURNACE I FAU GRAVITY-
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU=
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED IT
9 (commencing with Section 7000)of Division 3 of the Bust WALL
ness and Professions Code and my license is in full force and
effect
License Numberl-1-(�-ELK- Lie Class_Lr
Contractor Date_6'20-� ?
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a�registered professional engineer Plan check fee 15%of above
acting in my professional capacity (Section 7051 Bus Q
iness and Professions Code) PERMIT ISSUING FEE $ ,
Lie or Reg No Date TOTAL FEE Q
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME
License Law for the following reason (Section 7031 5 Bust
ness and Professions Code) ADDRESS "Z z?2 9,6 6 A
❑ I as owner of the property will do the work and the � #re o e o • 8
structure is not intended or offered for sale (Section CITY C TEL NO� 4f 47�/�
7044 Business and Professions Code) I OWNER \ r O/ 7 2 ° ° 3 0 50
❑ I as owner of the property am exclusively contracting I
with licensed contractors-,to,construct the project MAIL" r o a • 30 5 0-cm)
(Section 7044 Business and Professions Code) ADDRESS r 0 ^
0620-83
CONSTRUCTION LENDING AGENCY CITY 'TEL NO T si t
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec 3097 Civ C) r �+ t
Lender s Name ADDRESS
Lender s Address
CITY -TEL N0
i certify that I have read this application and state that the STATE Q [ LIC "
above information is correct I agree to comply with all County LICENSE NO J T CLASS
ordinances and State laws regulating Heating Ventilating and I
Air Conditioning and hereby authorize representatives of this SEE REVERSE hOR EXPLANATORY LANGUAGE _
M
to enter upon the above mentioned properly for
1a ur -)ses µ A M
Signature of Permittee Date