HomeMy Public PortalAbout4827 AGNES AVE_Mechanical_12/1/1980_ 364C
WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) b=�lfJ U-" UC AT�O u V FOR U'"E R IVU JT
1 hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company � - i L.
❑ COUNTY®� L®$ ANGELES 7_1 BUILDING AND SAFETY
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspectionADDRESS ,(,
BUILDINFOR .-- A
department. �OAPPL8C,4ftIY TO FILL IN ,/
Date Applicant (PRINT OR TYPE ONLY)
r
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EOUtPMENT FEE " - �
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. , y 0- .
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCE 'ED Y U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner Si 0
so as to become subject to the Wor ers' Co///���ppp .is tion Laws. BOILER, BTU
`/11 00 y�l APPROVALS DATE INSPECTOR'S SIGNATURE IU
Date./��IQ Applicant _ COMPRESSOR,BTU /-, ROUGH 7. V-FD N
NOTICE TO APPLICANT: If, after makir th' Certificate of VENTILATION SYSTEM FINAL -2-(-�� z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER�C� VALIDATION
with comply with such provisions or this permit shall be O�fL�E-21
deemed revoked. FURNACE: FAUFLOOR: BT
N/- GRAVITY
LICENSED CONTRACTORS DECLARATION ��
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 SS
effect. ,y
License Number �_- c.Class
Contractor i- ,112
❑ I am exempt rf am the licensing requirements as I am a p S 4
licensed architect or a registered professional engineer Plan check fee 25%of abae.
acting in my professional capacity (Section 7051, Bus- PERMIT
Bus-
iness and Professions Code).
Lic.or Reg.No. Date
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 �3 2 3 A
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO. # opo o o.4 1
7044, Business and Professions Code).
OWNER 5�' al-PC:M te, e �C) i'`y"a 2 ° 0 8700
El 1, as .owner of the property, am exclusively contracting � "" _
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS a �/�tl_�_/�{ / Q _%t ° ° O 8 7,0 Q 26
CONSTRUCTION LENDING AGENCY CITY TEL O. 2 O 1 ,_.8 O
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTORZZ/_ji OvId-
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS .Zb.-
Lender's Address CITY TE,w.NO.
I certify that I have read this application and state that the STATE,-" A .
above information is correct.I agree to comply with all County LICENSE NO. G� f CLLICASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter u the above-mentioned property for
iu a ion pu
Signature of erm a Date