HomeMy Public PortalAbout4847 3/8, 4853 AGNES AVE_Mechanical_10/5/1989_compressor, furnace, outlets WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
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I iereby affirm that I have a certificate of consent to self
oraure or a certificate of d certified}fed copy thereof Workers c8 0 LoobensCatlon Insurance 76A364C HEATING VENTILATING AIR CONDITIONING all
20 Policy No Company 0046 DPW 9/88
Certified copy is hereby furnished
COUNTY OF LOS ANGELES BUILDING AND SAFETY '
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Certified copy is filed with the county building inspecBUILDING .53tion department FOR APPLICANT TO FILL IN ADDRESS
it r � A (PRINT OR TYPE ONLY) awonAkgf -
Date Applicant LOCALITY G
i NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROS
(This section n'e'ed 'not be completed if the work involved by ABSORPTION UNIT BTU I I
I DISTRICT Mn ✓ PROLE Y
the permit is for one hundred dollars(;100)or less)
I certify that in the performance of the workJor which this AIR HANDLING UNIT CFM
permit is issued I shall not employ any person in any manner +
so as to become subject to the Workers Compensatio LOWS BOILER BTU APPROVALS DATE I SPECTOR 5 SIGNATURE
COMPRESSOR BTU
Applic 00
ROUGH
Dbt
NOTICE TO APPLICANT If afte'r making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers le ,
�n -'Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER ' V ID IO
with comp)Y with such provisions or this permit shall be deem w ,
ed revoked i i FURNACE FAU O „
" LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT_ a
' (commencing with Section 7000)of Division 3 of the Business HEATER WALL
s a and Professions Code and my liceense is in full force and effect
License� s
Nun-ba; Lic Class i ,a a 0
k + 4. poll.Contract G Dat ad =
Ti I am exemptunder Sec V
Plan check fee U
B 8P C for this reason a,.
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' Date PERMIT ISSUING FEE $ D T Z
Signature-- TOTAL FEE 5
'
' OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and' NAME
Professions Code)
s� ADDRESS'
❑ I as owner of the property or my employees with r _ ��.T.g
wages as their sole compensation will do the work and ,
the structure is not intended or offered for sale(Section CITY TEL NO ' ;,�� C f
7044 Business and Professions Code) OWNER ,3U .
50
❑ 'I as owner of the property am exclusively contracting - 1 ITEC;
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS Till AL * 5 1.50
CONSTRUCTION LENDING AGENCY a CITY i TEL L CHUX ~91.41
I hereby affirm that there is a construction lending agency for ' t
the performance of the work for which this permit is issued CONTRALTO loop.
.00(Sec 3097 Civ C ) r }
ADDRESS +^� srr�a
Lenders Name ti ?bL
eNS
TEL No -`,i��-d000—�1 ' 10/ 9/89
Lender s Address LIC 6 - 1 ^ AC '°'tib
I certify that I have read this application and state that the O ZC��" CLASS C ZQ i3• }
above information is correct I agree to comply with all County r
ordinances and State laws relating to building construction i y
and hereby authorize representatives of this County to enter
upon he bove menti ed pr perty for ins ection purposes - - '
SEE REVERSE FOR EXPLANATORY LANGUAGE M AK
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a ure of Applicant or Agent Date `
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