HomeMy Public PortalAbout4919 AGNES AVE_Mechanical_8/18/1992_compressor, furnace, inlet & outlets I t I
WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
_ I hereby affirm that I have a certificate of consent to self
igsure'or,,a certificate of Workers Compensation Insurance HEATING ` VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) 76A364C r
Policy No
' CE 818(REV-10/81) ,.
Company c
Certified copy is,hereby furnished COUNTY OF LOS ANGELES r BUILDING AND SAFETY
❑ Certified copy'is filed with the county building mspec FOR APPLICANT TO FILL IN - BUILDING
tion department t ADDRESS 7 l
� (PRINT OR TYPE ONLY)
Date h Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE Zi5
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE 4r CROSS ST AiZ�Gd f�
+ (This section need not be completed if the'work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars ($100)or less ) r �
AIR HANDLING UNIT CFM
t I certify that in the performarice of the-work for which this (/
permit is Issued I shall not employ any person in any manner _
so as to become subject to the Workers Compensation Laws BOILER BTU ? APPROVALS DATE INSPECTOR S SIGNATURE
-
Dacti /v 9,gpplicant,,j&6 ' COMPRESSOR BTU ��Z,, 0 a ROUGH 3
NOTICE TO APPLICANT `If after making tl�is+CertificotJ f VENTILATION SYSTEM FINAL _)
Exemption -you shouldi become subject to the Workers,
Compensation provisions of the Labortode you must forth EVAPORATIVE COOLER k r �, VALIDATION
with comply with such provisions or this permit shall be r t
deemed revoked FURNACE ^ FAU G AVITY ` }
LICENSED CONTRACTORS DECLARATION / FLOOR BTU B. c>
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL a
and Professions Code and my license is in full force and effect - D�
_ CL
/A// ZS' GG Cl t O
License Number Lic Class 6Z6. V
ly pool. 119
Conti�A$ _� Da'te k ��`7 j t r 0
❑ I am exempt under Sec V
�ry d
j _ _ i J y
B &P C for This reason Plan check fee"
PERMIT ISSUING FEES �
7 a
A Date TOTAL FEE ALICT'8
Signature il 7
OWNER BUILDER DECLARATION PLAN CHECK APPLICA%NT
I hereby affirm that I am exempt from the Contractor s License' t ITEMS s
Law for the following reason (Section 7031 5 Business and, NAME e
pool-
Professions Code) - I TOTAL 94. 23
❑ I as owner of the property or my employees with ADDRESS �� , (HE(K 94—.27
t
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO CHANGE o0I
7044 Business and Professions Code)
iti OWNER
❑ I as owner of the property am exclusively contracting 6,e 001//0 n'',,y
with'licensed contractors to construct the project (Sec ADDRESS J �- 9 i000—ceci irliu/9^
tion 7044 Business and Professions Code) t
_ CONSTRUCTION LENDING AGENCY CITY ' TEL NO � 5078 d 1 AMII: 4
I hereby affirm that there is a construction lending agency for -
the performance of the work for which"this permit is issued CONTRACTOR
(Sec 3097 Civ C ) C f ! 4 y
ti
Lender s Name f ADDRESS
r
CITY
Lender s Address `
STATE LIC
I certify that I have read this application and state that the LICENSE NO 3tCLASS
above information is correct I agree to comply with all County '
ordinances and State laws relatin to buildingconstruction
and h �Zesentafives
f this County to entero
o e property for cn purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date r