HomeMy Public PortalAbout4833, 4825 AGNES AVE_Mechanical_12/1/1980_ WORKERS'COMPENSATION DECLARATION CEA364C(2-so, \ G� )S C A S O N FOR p C R�l T
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,of
a certified copy thereof(Sec. 3800, Lab.C.) -y-
Policy No. Company
Certified copy is hereby furnished. COflJilITY OF SOS ANGELES BLDULDVWO c�N®S�4F[ETV
EJCertified copy is filed with the county building inspection
department. FOR APPLICANT TO FILL ON BUILDING
ADDRESS _7g r,3-3 ^
Date Applicant (PRINT OR TYPE ONLY)"
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CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST CRO S ST. G� %!� d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU — p
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCESSED Y V
I certify that in the,performance of the work for which this AIR HANDLING UNIT,CFM ' ,� CC
permit is issued, I shall not employ any person in any manner Q 0
so as to become subject to the Workers' Co p=V4CA_L_
Laws. BOILER, BTU
C APPROVALS DATE INSPECTOR'S SIGNATURE U
�`1 W
Date.,
Applicant. 2— COMPRESSOR,BTU �'% _ ROUGH' 7_��0 ,,,� Cn
NOTICE TO APPLICANT: If, after Makin th' Certificate of VENTILATION SYSTEM FINAL Z.j-F/ l Z
'Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be 0 01G
deemed revoked.
FURNACE: FAU-5e— GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU �(1
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT J
9 (commencing with Section 7000) of Division 3 of the Busi- WALL f/l
ness and Professions Code, and my license is in full force and
effect. /p 5-52.3—
License
Number Li Li .Class L- a
�y� j
Contractor 1--1 tom �uate
ElI 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 FIEF $ �7
Lie.or Reg.No. Date TOTAL FFF
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
I, as owner of the property, will do the work and the + # 0 0 o o (I,
_
structure is not intended or offered for sale (Section CITY TEL. NO. 1 I ,
7044, Business and Professions Code). OWNER 2 0 0 [I 7 0 0
El 1 /
I, as owner of the property, am exclusively contracting �+^!i Ny�/ `J '/B ����
with licensed contractors to construct t)a project MAIL ;/ Co'o.o (I,7,Q 0 C5
(Section 7.044, Business and Professions Code). ADDRESS (;► c I ���///
CONSTRUCTION LENDING AGENCY CITY TEL.igo. 2 0 til 8 0
1 hereby affirm that there is a construction lending agency T P
for the performance of the work for which this permit is CONTRACTOR ws A,W
issued(Sec. 3097,Civ.C.). — -
Lender's Name ADDRESS r
'r
Lender's Address CITY TEL.NO.
(J_/ 7
I certify that I have read this application and state that the STATE i r! LIC. 4 'A
above information is correct.I agree to comply with all County LICENSE NO.a��-�� CLASS`•^-
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County- to ente u n above-mentioned property for
ins ec n pure s
Signature of P6&il�v Date