HomeMy Public PortalAbout5746 AGNES AVE_Mechanical_9/27/1991_ ION
WORKER'S I have
a certificate
of consent to 76A346DPW9,89 APPLICATION FOR PERMIT. LIME GREEN
I hereby�affirrrti that I have a certificate of consent to self insure, 76A364C - ,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.) u
Policy No. Company COUNTY OF.LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITYc+
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE n4-pi-.c
t
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ;6
COMPENSATION INSURANCE CROSS ST. �.cJ
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, l shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: It, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GR VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 6'O VALID TION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
is
License Number Lic.Class
d
Contractor Date 0
❑ Plan check fee
I am exempt under Sec. it
B.&P.C.for this reason PERMIT ISSUING FEE$ Q U
Date: TOTAL FEE LU
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME �� ��
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS 4bJa=)
El 1, as owner of the property, or my employees with wages �(� !� N T�VV i i-I`;�f,-
as their sole compensation, will do the work and the TEL.NO. I =
structure is not intended or offered for sale (Section 7044, V rJG fAj -
Business and Professions Code). OWNER _ t I-ly3 i t` g 1 `„t
I, as owner of theproperty, am exclusive) contracting �1 {
Y 9 MAIL / �t/ t PA---f
� �,- t Ei t»�
with licensed contractors to construct the project (Sec- ADDRESS A6 m(5s AA CH
f.-:r -
tion 7044, Business and Professions Code). :»HANDL� e 131-1
CONSTRUCTION LENDING AGENCY CITY C1! TEL.NO. jL
I hereby affirm that there is a construction lending agency for CONTRACTOR v�
the performance of the work for which this permit Is issued L
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIQ
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
re,pLqentatIves of this County to enter upon the above-mentioned
rop ty for inspect' n p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNA RE OF APPLICANT-OR A DATE