HomeMy Public PortalAbout5733 AGNES AVE_Mechanical_12/29/1989_ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have,,a •certificc+,e.2f•conseflt to self
insure, or a certificate of Workers' Corrtpensation Insurance, - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab, C') 76A364C
Polic
Wo.Cm 0019209- @d mpany GEN. ACCIDENT CE-818(REV. 10/81)
❑ 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
lT tion department. (PRINT OR TYPE ONLY) ADDRESS 57330L AGNES AVENUE T.C.
Date 12-21—Mpplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC E BY
the permit is for one hundred dollar's ($100)or less:)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this tt...✓✓ UUU i
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 IN ECTOR'S SIGNATURE
Date Applicant COMPRESSOR; BTU48 QQQ JCI — ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,.you must forth- EVAPORATIVE COOLER VA DA 1 N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE:. FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR 8717 1 —
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
and Professions Code,-and my license is in full force and effect.
t>�
License Number 261695 Lic. Class C-20 — ' U
O
12 Inlets and outlets 2
Contr&JorrQ T HT(' A__C ate 12-21-89
❑ I am exempt under Sec.
Plan check fee IL
H
B.BP.C. for this reason �
Date: PERMIT ISSUING FEE $
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
33�1! 11'q'=Lit
Law for the following reason (Section 7031.5, Business and NAME J. & J. HTG. 8
Professions Code): A C 1 ITEMS
ADDRESS
• ❑ I, as owner of the property, or my employees with 2379 FIRST ST. 51 -50
wages as their sole compensation;will do the*and and — TOTAL
�YflY_ CITY TEL. NO. q
the structure is not intended or offered for sal tion f 'St .50
7044, Business and Professions Code). OWNER
❑ owNER RON DERTH �':HANGE ,Eii
I, as owner of The property, ani exclusively contracting -
with licensed contractors to construct the project (Sec- MAIL 9109 LAS TUNAS DR.
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1 ,� 291" 5'
I hereby affirm that there is a construction lending agency for (818) 282-797 CI1Li— <i i� fir/
the performance of the work for which,this permit is issued CONTRACTOR , /864 I AM 9-
(Sec. 3097, Civ. C.). AND AZ C
ADDRESS )'179 FORST D
Lender's Name
CITY LA VERNE 91750 TEL. No. In 593-3353
Lender's Address
STATE LIC. J
I certify that I have read this application and state that the LICENSE NO. �C�O b'( CLASS o[.�
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
an ereby authorize re resentatives of this County to enter 1
pont abo e d If perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant ent Date