HomeMy Public PortalAbout4829 AGNES AVE_Mechanical_12/1/1980_ 1 nn
WORKERS COMPENSATION DECLARATION CEA 8G18C(2 80) APPLICATION FOR PERWT
T
I hereby affirm that I have a certificate of consent to self i
insure or a certificate of Workers Compensation Insurance or `' d HEATING-VENTILATING-AIR 'CONDITIONING
a certified copy thereof(Sec 3800 Lab C) r
Policy No Company
0 Certified copy is hereby furnished -L ,� COUNTY OF LOS ANGELES BUILDING AND SAFETY
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D
Cectified,copyris filed with the couynty building inspection FOR APPLICANT TO FILL iN ADDRESS
BUILDING
department
` �' `!
Date-.Applicant ' ° (PRINT OR TYPE ONLY)' '
r R A LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO s TYPE OF'APPLIANCE OR EQUIPMENT < FEE _ y •+
'COMPENSATION INSURANCEa i + , V c NEAREST ,
(This section need not be completed if the work involved ABSORPTION UNIT'BTU CROSS ST _ O
by the permit is for one hundred dollars ($100) or less) i ' = DISTRICT NO PROCESSED 9Y r ()
I certify that in the erformanee of the work for which this AeR HANDLING UNIT CFM 4"
permit is issued I shall not employ any person in any manner "' v ' d O
so as to become subject to the Wor rs Co a io Laws IBOILER BTU
p-1a - APPROVALS DATE INSPECTORS SIGNATURE t;.l'
Ilk
Date Applicant y COMPRESSOR BTU ins �v ROUGH y �,"cf-fD N
NOTICE TO APPLICANT If after makin th r Certificate of r
VENTILATION SYSTEM " � L Z
Exemption you should become subject to the Workers } FINAL,,
Compensation provisions of the Labor Code you must forth LE EVAPORATIVE COO ' VALIDATION
with comply with such provisions or this permit shall be .5,&�
deemed revoked r s t ' FURNACE FAU L- GRAVITY
LICENSED CONTRA(TORS DECLARATION " S FLOOR BT sb
I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENREDr,, 'UNIT
9 (commencing with Section 7000)of Division 3 of the Busi t WALL '1laf/71-e,J
ness and Professions Code and my license is in full force and . r
effect
a .. +4 ♦ .L .� Y ) i
License Number is Class
Contractor
I am exemp from the licensing requirements as I am a o
licensed architect or a registered professional engineer Plan„CheCk fee 25%of above
acting in my professional capacity (Section 7051 Bus ,
iness and Professions Code) s d PERMIT ISSUING FEE$
Lie or Reg No Date ~ i a -- - TOTAL FE£ - �67
HOME OWNER BUILDER DECLARATION , PLAN CHECK APPLICANT '`:'
. t .
`I hereby affirm that 1 am exempt from the Contractors NAME
' License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) ADDRESSA
I as owner of the property will do the work and the ` » "~
structure is not intended or offered for sale (Section . CITY TEL NO �''J 2 4 fl
7044 Business and Professions Code) - p
,' . OWNER `
Da I as owner of the property am exclusively contracting , L� G`? �N,• - #lei-i- - 4 1 r i
with licensed contractors to construct the project MAIL t' j
(Section 7044 Business and Professions Code) ' ADDRESS +- _� � N 'y 2 - 0,700
1 � r
CONSTRUCTION LENDING AGENCY CITY - � V - TE O " - - 1 �Z.0 0�
1 hereby affirm that there is a construction lending agency - ^t t
for the performance of the'work for which this permit is CONTRACTOR Gs - T f�Y i 1' 120,1 -$0
issued(Sec 3097 Civ C) * + P
Lender s Name s ADDRESS `
i»
41
Lender s Address r CITY' _ EL NO
I certify that I have read this application and state that the x STAT ° LIC '
above uiformation is correct I agree to comply with all County I LICENSE NO "s CLASS -p7a rY ,
ordinances and State laws regulating Heating,, Ventilating and
Air Conditioning a hareby authorize representatives of this 1 SEE REVERSE F,,LR EXPLANATORY LANGUAGE
County to enter po J"ove mentioned property for { ' - - r
rasp ct 9 purpo -ge r
1_ -e
Signature of Pe itte Date J