HomeMy Public PortalAbout5925 AGNES AVE_Mechanical_12/1/1993_ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
9.1by''affirm that I have a certificate-of consent to self insure," APPLICATION FOR PERMIT
76A364C L I M E GREEN
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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 3 /
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.), MAP BOOK PAGE PARCEL
AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU-
become
TU become subject to the Workers'Compensation Laws. v (J
j �Tn COMPRESSOR,BTU
y C"cV`, ,• ��-��,VyI� �:,//irY/• APPROVALS DATE INSPECTOR'S SIGNATURE
`Date f Zy' Applicant Z VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH V-2
Exemption, you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ,
provisions or this permit shall be deemed revoked. FURNACE: FAU I GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ZS (pS VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect. ' Ir
9 AID �1
License Number Lic.Class
IL
Contractor Date 0
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ 26 - O
Date: TOTAL FEE , `tj' W
Signature CL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �/� V)
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason:(Section 7031.5, Business and Professions
Cole): ADDRESS - 8
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER ?
❑ I, as owner of the property, am exclusively contracting T� •� ,t _-
MAIL Tf I['pL. .8.'"V 4 m �5
with licensed contractors to construct the project (Sec- ADDRESS ��w� C�
tion 7044, Business and Professions Code). ;�j�l;�� y
CITY TEL.NO.
4.
CONSTRUCTION LENDING AGENCY t
I hereby affirm that there is a construction lending agency for CONTRACTOR , f,6-�ANGE +00
L-�
the performance of the work for which this permit Is issued 19LlN _
(Sec.3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO. j ; A'-.t -
i j s1 i =40
Lender's Address STATE LIC.
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
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATU E OF APPLICANT OR AGENT �- DATE