HomeMy Public PortalAbout5219 AGNES AVE_Mechanical_7/18/1983 I a .
WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) Q p p(���Q Uo �I FOR p Cl
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HZATONG-V ENTILATiNG-AIR CONDIT10f` ONG U
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO,FILL IN BUILDING
department. j
.� /�
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE , V
COMPENSATION INSURANCENEAREST ` ( >_(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. �/ 1—✓� a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. ! PRo12 ^BY 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM _--7 cc.
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILEA, BTU I—
APPROVALS DATE INSPECTOR'S SIGNATURE W
Date-7-IT-4 Applicant: ���4 COMPRESSOR, BTU-q-'-?4�CQ ROUGH ��/ circ -E CL
NOTICE TO APPLICANT: If, after makin this Certifica e of VENTILATION SYSTEM FINAL �f/ m� z
Exemption, you should become subject to the Workers' —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
ip
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU GRAVITY � '�
LICENSED CONTRACTORS DECLARATION FLOOR: BTU_/�Q—�
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number tic.Class 2G0
Contractor Date 's Jp
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ j
Lie.or Reg.No. Date TOTAL FEE e�
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS z 3 7 G,7 A
I, as owner of the property, will-do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section #•0 0 0,0 0 8
7044, Business and Professions Code). ' '
OWNERo 0
I, as owner of the property, am exclusively contracting r 'I�erJ�� /, 3 0,.5.0
with licensed. contractors to construct the project MAILs
(Section 7044, Business and Professions Code). ADDRESS 'Z f ,_�j�l� o 0 0 3 Q v Q v
CONSTRUCTION LENDING AGENCY CITY NO.-1 �1)�f rf,�t3 O 718-83
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued
T-f� i/_j �
issued(Sec. 3097,Civ.C.). / 2
Lender's Name ADDRESSL� e 0,9,kRV
p_2_7� L/
Lender's Address CITY TEL.NO.
'i�t'1
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. f CI CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
insp ction purp ses.
_ T-
Signature of Per ttee f Date