HomeMy Public PortalAbout5732 AGNES AVE_Mechanical__ WWURIZEkS COMPENSATION DECLARATION CEA 818(2 80) A P D L IC A T V®fry F®R F S R M IT
1 hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance or HEATING-VENT) AiTING-AIR CONDITIONING
a certified copy thereof(Sec 3t+' i Lai C) (�
Policy No Cor far — _ 7" r
Certified copy is} reby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified cy is filed with the county building ins ettion BUILDING
dna (i� }',>, y/4 FOR APPLICANT TO FILL IN ADDRESS _
Dated�fl�Applicant "�`e�=� r�� (PRINT OR TYPE ONLY)
LOCALITY C
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST d
}
CROSS ST
Ii section need not be completed if the work involved ABSORPTION UNIT BTU O
by the permit is for one hundred dollars ($100) oI less) DISTRICT NO PROCESS D BY (�
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM S Or it
permit is issued I shall not employ any person in any manner t 0O
so as to h coin subject to t�,ers Compensation Laws BOILER BTU
ff APPROVALS DATE INSPECTOR S SIGNATURE IU
Applica _ _ —_ / COMPRESSOR BTU ROUGH �Z a Z
NOTICE 10 APPLICANT If after making this Certificate of VENTILATION SYSTEM _
h,xemptior4 you should become subject to the, Workers FINAL
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 CR VIT .,
LICENSLD CONTRACTORS DEQLAR ATION FLOOR BTU/ & =
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT J 370
9 (commencing with.Section 7000)of Division 3 of the Bust WALL
ness and Professions Code and my license is in full torte and
effect
License N imbe jail Class
U /_ami /��
..enactor_ Date
�1 I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus PERMIT ISSUING FEE $
loess and Professions Code) ¢�
Lie or Reg No Date TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
s
I hereby affirm that I am exempt from the Contractors NAME J
License Law for the following reason (Section 7031 5 Bust —
ness and Professions Code) ADDRESS _ 2260,1 A
ElI as owner of the property will do the work and the
CITY TEL NO
structure is not Intended or offered for sale (Section Y - # 0 0 0 0 4
7044 Business and Professions Code) "
❑ T OWNER — — 2 0 0
I as owner of the property am exclusively contracting � 2700
with licensed contractors to construct the project MAIL _
(Section 7044 Business and Professions Code) ADDRESS _ roho 0 2'7 0 0
1 Q14_80
CONSTRUCTION LENDING AGENCY CITY TEL NO I 1 I
I hereby affirm that there is a construction lending agency T^
for the performance of the work for which this permit is CONTRACTOP �YZ
issued (Sec 3097 Civ C) -
Lender s Name ADDRESS r�OQ
Lenders Address CITY /V TEL NO �7/�L/� H
� T +
1 certify that I have read this application and state that the STATE /-2
LIC
above Information is correct I agree to comply with all County LICENSE NO _ � / !. CLAS$ �� e
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning and hereby authorize representatives of this SEE REVLRSE FOR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for
,spar �n pis rs-
Signature�r YermrtYee Date _