HomeMy Public PortalAbout5813 AGNES AVE_Mechanical__ RKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
/insure bygraafcertif cane of Workers haI have a rtCompensation Insurancificate of consent to e
or a certified copy thereof (Sec 3800 Lab C ) 76A364C HEATING - VENTILATING AIR CONDITIONING
CE 818(REV 10/81)
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 ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST i
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars ($100)or less)
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this ✓ ` O
permit is issued I shall not employ a y person in any manner
so as to be omN
ect to the Wor r Co npen n Laws BOILER BTU APPROVALS DATE T 5 SIGNAT RE
S J f COMPRESSOR BTU ROUGH
Date Applicant
NOTICE A LICANT 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 All I N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GBAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 04
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 effect41
License Number Lic Class SS , r V
OC
Contractor Date 0
❑ I am exempt under Sec S!
Plan check fee ILi
B &P C for this reason An
�� �
PERMIT ISSUING FEE $
Date TOTAL FEE Lj 6t_s 9 9 6 13 A
Signature
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Ic # o • o • 0 8
1 hereby affirm that I am exempt from the Contractor s License --y
Law for the following reason (Section 7031 5 Business and NAME ��y�7j 1V
P fessions Code)
I as owner of the property or my employees with ADDRESS C � ( 0 . 5&75
wages as their sole compensation will do the work and CITY G TEL NO5 (� '
the structure Is not intended or offered for sale(Section
7044 Business and Professions Code) $ 0056,755
❑ I as owner of the property am exclusively contracting OWNER
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS 0 5 8
CONSTRUCTION LENDING AGENCY CITY TEL NO V
I hereby affirm that there is a construction lending agency for '
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS - -
Lender s Name
CITY TEL NO
Lender s Address
STATE LIC
I certify that I have read this application and state that the, LICENSE NO ir- CLASS — �-
above informs correct I agree to comply with all County
ordJOE&V
nd SMentiod
llting to building construction
antatives of this County to enter
upperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant or Agent Date -