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HomeMy Public PortalAbout5803 AGNES AVE_Mechanical_7/7/1989_ WORKERS COMPENSATION DECLARATION / + APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to'self Insure or a certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING or a certified copy thereof (Sec 3800 Lab C ) 76A364C 20 0046 DPW 9/88 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 tion department s > 4 Al�f 1! (PRINT OR TYPE ONLY) Datelei Lz Applicant '�� v r-1__o11'fU'YI r LOCALITY ;�� NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST I J COMPENSATION INSURANCE CROSS ST LAg 3 (This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESS the permit is for one hundred dollars (;100) or less) I certify that in the performance of the work for which this r AIR HANDLING UNIT CFM permit Is Issued I shall not employ any person In any manner so as to become subject to the Workers Compensation LOWSBOILER BTU�� / � APPROVALS DATE INSPECTOR$SIGNATURE Date ` �� Applicant -Qy �'�^' COMPRESSOR BTU 3o�soa ROUGH NOTICE TO APPLICANT If after maks g this Certificate of VENTILATION SYSTEM FINAL ©`Z 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 deem 11 ed revoked . , t FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 977 HEATER SUSPENDED UNIT (commencing with Section 7000)of Division 3 of,the Business �C WALL Q and Professions Code and my license Is in full force and effect } License Number IO�ga Lic Class C' Q O Contractor -Date 8� v ❑ 0 I am exempt under Sec Plan check fee ,v„ B&P C ffor this reason t H Date PERMIT ISSUING FEE $ Z Signature k ITOTAL FEE OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor s License ® _ Law for the following reason (Section 7031 5 Business and NAME Professions Code) d F1I as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and _ °9 ACfiT i CITY_ TEL NO the structure is not intended or offered for sale (Section v -� 7044 Business and Professions Code) OWNER '` r 3307 - 50°5I F-1 �r� N t+ALL p I as owner of the property am exclusively contracting 1 ITEfr,rc '� with licensed contractors to construct the project (Sec MAIL /� tion 7044 Business and Professions Code) ADDRESS 5 os ACsN�S TOTAL T50o50 CONSTRUCTION LENDING AGENCY CIT TEL NO �1L I hereby affirm that there is a construction lending agency for ��_� C CHECK .90■50 t(Sec 3097 Civ C )he performance of the work for which this permit Is issued CONTRACTOR , _ �H�� .00 ADDRESS Gj(,0'4? E L fbc4E _ Lender s Name `.`w -yam /� CITY Q E L VvWµ� TEL NO S'I !O /V jM1 7/ 7!c87 Lender s Address Q I certify that I have read this application and state that the SATE NO 1� x f CLALIC SS C''a� 43, 1 AM11:'t7 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 on the above ment. .(a�f(�(�coned I?ropy�rty for Inspection purposes N Y "i \v�\,(� SEE REVERSE FOR EXPLANATORY LANGUAGE Signatulle of Applicant or Agent Date Os