HomeMy Public PortalAbout4857 AGNES AVE_Mechanical_10/5/1989_ r WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self , 0
insure or a certificate of Workers Compensation Insurance 76A364C ' HEATING - VENTILATING AIR CONDITIONING e
or a certif ed copy thereof (Sec 3800 Lab C) -
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Policy No Company Certified copyis hereby furnished t y 'COUNTY OF LOS ANGELES BUILDING AND SAFETY f
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+Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING
,,tion department ; r i (PRINT OR TYPE ONLY)+ r ADDRESS ,
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Date Applicant " � LOCALITY
4 'r NO TYPE OF APPLIANCE OR EQUIPMENT - FEE
- h ,CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST ' x
,i COMPENSATION INSURANCE _ CROSS S
t (Tuts section need not be completed if the work involved by ABSORPTION UNIT' BTU ' ' DISTRICT NO PROCE,%6 BY yo
the permit is for one hundred dollars(;100) or less) - y n"..
AIR HANDLING UNIT CFM 0� A>
I certify that in the performance of the work for which this � ,
permit is issued I shall not employ any person In any manner
t50/aS„to become subject to the Workers Compensation Laws BOILER BTU� �/ APPROVALS P DATE INSPECTORSIGNATURE
1.i aTe �✓� ApplicM�� ^ ' COMPRESSOR BTU / 00 ROUGH s
,NOTICE TO APPLICANT If after making this Certificate of,. VENTILATION SYSTEM x.. , r, FINAL ,
Exemption you should become subject'to thet Worker`s ` +
Compensation provisions of the Labor Code you-must forth EVAPORATIVE COOLER e „ TYON '
r s with comply with such provisions or this permit shall be deem I
ed revoked a 'FURNACE FAUGR VITY / -00 .
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' LICENSED CONTRACTORS DECLARATION, - FLOOR _.
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{I hereby affirm that'I am licensed under provisions of Chapter 9 1HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL { t
r` and Professions Code and my license is in full force and effect
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Lic Class
` OLicense Num �
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M,.1 am exempt under Sec U s
Plan check fee
' B 8P C for this reason
Date PERMIT ISSUING TOTAL FEE $ , c Z
FEE
Signature _ +
OWNER BUILDER DECLARATION .,
PLAN CHECK APPLICANT
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[he'
affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
; r ADDRESS"' , �+ /� T S
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I as owner of the property or my employees with C•/'
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wages as their sole compensation will do the work and 3307
the structure is not intended or offered for sale( Section rw CITY� �ne -+� TEL NO a f �`
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7044 Business and Professions Code) _ OWNER ;r ' " t v + 1 ITEMS
❑ I as owner of the property am exclusively contracting r r
with licensed contractors to construct the project (Sec MAILT�Ttit. 50
;n, y tion 7044 Business and Professions Code) ADDRESS r
i t CONSTRUCTION LENDING AGENCY' CITY , TEL NO ! M , e C.HECY T1.5CI
I hereby affirm that there is a construction lending agency for `" +, > y r-
the performance of the work for which this permit Is issued CONTRACTOR ",
(Sec 3097 Civ C) " ` , 0
ADDRESS
Lender s Name "DOW—OWI- 10, 5/?1
t„ CIN ' TEL ��
Lender s Address
STATE LIC ' rj}V07. 1 AM u 4U
I certify that Phave read this application and state that the LICENSE NO-2-32,6 CLASS C .Z,a
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 ti 1
upon th above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
,
ignature of Applicant or Agent t r Date t r 4 ; T ' ®S
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