HomeMy Public PortalAbout5226 AGNES AVE_Mechanical_12/29/1988_compressor, furnace WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
' I lierebp c`tfirm that I have a certificate of consent to self
insure or a certificate of Workers`Compensation Insurance 76A364C HEATING - VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) CE 818(REV 10/81)
Policy No Company Certified 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 r
tion department (PRINT OR TYPE ONLY) ADDRESS ZZ(p
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed of the work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED
the permit is for one hundred dollars ($100)or less )
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM CV_
permit is issued I shall not employ any person In any manner
so as to become subject to the Workers Compens ion Laws BOILER BTU APPROVALS DATE NSPECTOR S SIGN RE
Date - '+ pplican COMPRESSOR BTU Q ROUGH b—�/�� d►�
NOTICE TO PLICANT If after makin this Certificatey.- VENTILATION SYSTEM FINAL �� ic
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY /���`��
LICENSED CONTRACTORS DECLARATION FLOOR BTU (7(J
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER WALL SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business }
and Professions Code and my license is in full force and effect
License Number Lic Class , V
OC
Contractor Date 0
-
I am exempt under Sec W u
Plan check fee # 1 4 H
B &P C for this reason Z
PERMIT ISSUING FEE $ —
Date
Signature TOTAL FEE 1--301,S-O b o 0 0
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License , 1229-88
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) T i
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and CITY TEL NO
the structure is not intended or offered for sale(Section ,
/ 7044 Business and Professions Code)
IL7J( OWNER
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
CONSTRUCTION LENDING AGENCY CITY TEL NO
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 ) _
ADDRESS `
Lender s Name
CITY _ TEL NO
Lender s Address r
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS
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
up o the above rrlenti ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Iicant or Agent ate