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Home My Public Portal About4847 1/2, 4855 AGNES AVE_Mechanical_10/5/1989_compressor, furnace, outlets WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that 1 have a certificate of consent to self Insure or a.certificate of Workers Compensation Insurance r HEATING - VENTILATING AIR CONDITIONING ` or a certified copy thereof (Sec 3800 Lab C ) 76A364C 20 0046 DPW 9/88 ` Policy No Company f ❑ Gertified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY �❑ Certified copy Is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING/� tion department (PRINT OR TYPE ONLY) A el— ADDRESS L1f1 r r Date ApplicantLOCALITY a • NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST + COMPENSATION INSURANCE J CROSS ST I (This section need not be completed if the work'Involved by ABSORPTION UNIT BTU DISTRICT NO PROC S the permit Is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM -�? rl certify that in tile performance of the work for which this � permit Is Issued I shall not employ any person'in any manner : cccJJJ r so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTOR S SIGATURE + 97 no �� w �A COMPRESSOR BTU a ROUGH at App con r �s � i NOTICE TO'APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Exemption you should become subject to the Workers / r • t, Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER A IO with comply with such provisions or this permit shall be deem ed,revoked ,r x y FURNACE FAU VIN i a+ + LICENSED CONTRACTORS DECLARATION FLOOR BTU (/ + I hereby affirm that''am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT- (commencing USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business WALL +. and Professions Code and my license Is In full force and effect IL License NNumbe Lic Class lCz O ' 0 Contractor + Date09� J ^�v , ad F I amrexempt under Sec F1. V r �r r Plan check fee B&P C for this reason 11' ' 1 PERMIT ISSUING FEE $ ' . Z r TOTAL FEE r r Signature � + OWNER BUILDER DECLARATION PLAN CHECK APPLICANT r I hereby affirm that I am exempt from the Contractor s License c Law for the following reason (Section 7031 5 Business and NAME , ) Professions Code) I as owner of the property or my employees with ADDRESS CO y ` wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section CITY TEL NO 307 taeS 51.511 7044 Business and Professions Code) OWNS 1 ITEM I as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec MAIL tion 7044 Business and Professions Code) ADDRESS TUTfIL- 5 I- 50 CONSTRUCTION LENDING AGENCY CITY r TEL {HECK 51. 0 1 hereby affirm that there is a construction lending agency for ^ the performance of the work for which this permit is IssuedCHANGE CON7RA'CTOR , •�L (Sec 3097 Civ C ) } _ IF ` ADDRESS yr Lender s Name _ CITY TEL -- 0000-0001 10/ 5/19 TIVLender s Address �� 6055 1 ASI 8;4U I cern that I have read this application and state that the E LIC certify PP LICENSE N CLASS above Information is correct I agree to comply with all County i ordinances and State laws relating to building construction r 16 N "' and hereby authorize representatives of this County to enter upon e bove mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE > z Signature of Applicant or Agent Date es