HomeMy Public PortalAbout5806 AGNES AVE_Mechanical_11/30/1984_ 76A364C
WO K> `` u 'r''ENSATION DECi ARATION CE -818 (2-80) G If I�.Llm�C 6=J II O p V FOR1�L�If1S II�/U �T
I`hereby-aTt�fµ'hat"t have a certificate ofconsentto self
insure;or;�-rrtiicate of Workers'Compensation Insurance,or I
a certified copy thereof(Sec. 3800,Lab.C.) HEATING-V ENTIIL.ATING-AIR CONDITIONING
Policy No. Company
Certified copy.is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection
department. FOR 4PPLICANT TO FILL IN ADIDRESS t•Q p�/�� NSVC7,
Date Applicant (PIIZINT OR TYPE ONLY) + (>CJKJ�r—K-i
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF AP LIANCE OR EQUIPMENT FEE LOCALITY' j¢�,ti p' r
COMPENSATION INSURANCE CROSS ST
�
(This section need not be completed if the work involved ABSORPTIONUNIT, BTU CROSS ST.
by the permit is for one hundred dollars ($100) or less.) I DISTRICT NO. a / 'ROC E _D v OU
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
�St C 0
permit is'issued, I shall not employ any person in any manner I ( Q
so as to become subject to the Workers' Comp e ation Laws. BOILER, BTW H
I APPROVALS DATE INSPECT R5 SIGN URE IU
DateF �" �'�-I Applicant_{ �. - � COMPRESSOR, BTU I ROUGH LU
NOTICE TO APPLICANT: If, after makii is Certificate of VENTILATIOIN SYSTEM Z
Exemption, you should become subject to the Workers' I FINAL
Compensation provisions of the Labor Code, you must forth-
` EVAPORATIVE COOLER VALID TION
1 with comply with such provisions or this permit shall be � i
deemed revoked. FURNACE: FAU GRAVITY 1
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
�I hereby affirm that I am licensed under provisions of Chapter , HEATER: SUSPENDED UNIT ;tet
,. (commencing with Section 7000) of Division 3 of the Busi WALL
less and Professions Code, and my license is in full force and f ��
Yfect. -1-
icense Number_ 7 Lic.Class j '
�-Contractor, '/,.
•Date�f_� '- � � 1 1 a q � {
# o o o 0 o
I am exempt from, the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25% of above. I 1. ° 02050
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). - PERMIT ISSUING FEE $ o 20, 5006
Lic.or Reg.No. Date I TOTAL FEE 2,61 so1 '1.3 0.-8 4
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT i
i
I hereby affirm that .I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
ElI, as owner of the property, will do the work and the i
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code).
aOWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 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 CONTRACTOR
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL. NO. I ,
I certify that I have read this application and state that the STATE LIC.
above information is correct. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERS FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspec ion purpos s. I
Signature of rmlt Date
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