HomeMy Public PortalAbout5943 AGNES AVE_Mechanical__ Z7 * ECOMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affaffwntrn that I have a certificate of consent to self
insur3 or a cer(ificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C 76A364C HEATING - VENTILATING - AIR CONDITIONING
)
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cv G�L�C o m pa•Y�/�'{� C�n
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
D---c-lertified copy is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING IrR
tion department (PRINT OR TYPE ONLY) ADDRESS 15 S
Date?)''5' ic�Applicantll%.� X"- !ay �T• LOCALITY
�— NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by
ABSORPTION UNIT BTU DISTRICT NO PROCESSED
the permit is for one hundred dollars ($100)or less )
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I certify that In the performance of the work for which this AIR HANDLING UNIT CFM 6 J t V
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER BTU / APPROVALS DATE INS# R S SIGNATu
Date Applicant COMPRESSOR BTU ( Oo ROUGH 7
.�
NOTICE TO APPLICANT 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 VALIDATI N
with comply with such provisions or this permit shall be _
deemed revoked FURNACE FAU G VI
TY JI D fl
LICENSED CONTRACTORS DECLARATION FLOOR BTU (f v
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license is in full force and effect }
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License Number�Jm_- 12+ Lic Class s2 V
OC
Contractor 141405" S�:Date-a—114 CZ, O
F-
❑ I am exempt under Sec W
Plan check fee Ill
y
B 8P C for this reason PERMIT ISSUING FEE $ ;24229A Z
Date
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License r ( ° ° 3 0 5 0
Law for the following reason (Section 7031 5 Business and NAME c e 0 305020:
Professions Code)
❑ I as owner of the property or my employees with ADDRESS °
1 3—8 6
wages as their sole compensation will do the work and 0
CITY TEL NO
the structure is not intended or offered for sale(Section
7044 Business and Professions Code)
OWNER
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency for P111111"the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C )
t"
ADDRESS S
Lender s Name
CI TEL NO '
Lender s Address
STATE LIC
certify that I have read this application and state that the LICENSE NO CLASS a0
above information is correct I agree to comply with all County n�
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter
upon the above me tioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE '
Signature of Applicant or Ag t Date