HomeMy Public PortalAbout4840 AGNES AVE_Mechanical_11/6/1989_ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
�Y hereby affirm Choi I have a certificate of consent to self =
Insure or a certificate of Workers Compensation Insurance 76A364C HEATING - VENTILATING AIR CONDITIONING o
or,p certified6copy thereof (S4.ec 3800 ALab�.0/1�� �p
ipollcy o" Company ��"DPW 9/88 4 ` ' a
wY -CJertifled copy is hereby furnished COUNTY OF LOS ANGELES , BUILDING AND SAFETY
X r ak � L 6 '
1Certified copy Is filed with Lthe county bull spec FOR APPLICANT TO FILL IN ' BUILDING ��,�//� ,�+
r Tion department ADDRESS &/V & s
z � a� a r l � (PRINT OR TYPE ONLY)
4tf 'Date ` Applicant , LOCALITY ;
p ,,.,� y NO TYPE OF APPLIANCE OR EQUIPMENT FEE,
x i+ CERTIFICATE OF EXEMPTION FROM WORKERS a } NEAREST
'COMPENSATION INSURANCE `r . x° CROSS 57 I&Sil
'6ABSORPTION UNIT BTU
.4 (This section need not be completed if the work involved by DISTRICT NO
a, the permit is for one hundred dollars ($100)or less) ' /�
I certify thaf.ln the per-for mance�of the work for which this;r ; AIR HANDLING UNIT CFM U Jvj
'permit is Issued I shall not employ any person In any manner r BOILER BTU i ' y
so as to become subject to the Workers Compensation Laws Y APPROVALS DATES INSPECTOR S SIGNATURE
Date Applicant
COMPRESSOR BTU � D O ROUGH j
' NOTICE TO APPLICANT If after making this Certificate of art VENTILATION SYSTEM t FINAL
t Exempt or? you should become' subject to the Workers
° Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER w� j i V LID I N `
0 with,comply with such provisions or this permit shall be deem
ZO 4 ed revoked s s f, N NN P FURNACE * FAU
'ev' , LICENSED CONTRACTORS DECLARATION ` } FLOOR BTU
-1 hereby off irmxthat I am licensed under provisions of Chapter 9 o HEATER SUSPENDED UNIT_
+(commencing,with Section 7000)of Division 3'of the Business WALL `
and Professions Coe and my license Is In full force,-and effect a
License Number. Lic Class11 r t t O
r
Contractor - Date 4 , + ' -ad
,i'►;kc Iexempt ► O
am underSec I.-
WPlan check fee
B 8P C for this reason PERMIT ISSUING FEE ;r i'J ;� t ` '� y
Date f " t a` Z
�� J TOTAL FEE t 7
' ,
r, Signature i ti •a ,
r OWNER BUILDER DECLARATION PLAN CHECK APPLICANT `
" r I heieby affirmhthat I am exempt from the Contractors License ► sk
Law for the following reason (Section 7031 5 Business and NAME !
Professions Code) re
�I as owner of the property' or my employees with ADDRESS—
- 37 t y
t - wages as their sole compensation will,do the work,and ` t t 4( ' pCi_T,s
( CITY .-.w r Y'V A)- , +TEL NO-Ad,--751,at 4
.. .-the structure is not Intended or offered for sale Section Vi rt i �� r I ,.� � •,e
S 7044 Business and Professions Code) -`
❑ Y x , OWNER t x r . t a , ' V7 y e
p, I as owner of the property am exclusively,contracting a 1 ITEPI3
r w"Ith licensed contractors to construct the project (Sec MAIL �!� Y ` ' g ,
+ tion 7044 Business and Professions Code - ADDRESS 0 i + xx
CONSTRUCTION LENDING AGENCY CITY TEL NO I I�AL _•.�'JZ7 o r �,
�I hereby off irm"that there is atconstruction lending agency for - r v j , CWCK meq.(tel
the performance of the worktfor which this permit is issued CONTRACTOR } r �r
(Sec 3097 Civ C ) ' E' Y C44ANGE 00
s ' ` ADDRESS a
� i a
Lender srName {ry{�f a ,y {,. f
r CITY-1 � TEL NO'r7`��Z� . 1 � t LIViJV��Ji.l.�1 ��j �/+`!C
! V
Lender s4Address rr /'�`
}1 certify that I have read this application and state that the
[STA
E NO �J 7 CLASS Gla ` t 4 ~� 165°7 1 AM10+rU9
' above Information is correct I agree to comply with all County,
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter a
upon the above mentioned Property for inspection purposes ' SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent r Date 4L ®s
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