HomeMy Public PortalAbout5947 AGNES AVE_Mechanical__ WORKER'S COMPENSATIONDECLARQ.TION• 76A366DPW9,69 APPLICATION FOR PERMIT LIME GREEN .
76A364C
hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab.CJ
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.:
❑ LLLJJJ
Certified copy is hereby furnished.
® Certified copy is filed with the county uilding inspection FOR APPLICANT TO FILL IN BUILDINGS�� �
department. (PRINT OR TYPE ONLY) ADDRESS
Date -7.•-f 13 Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �,7/,/p
CERTIFICATE OF EXEMPTION FROM WERS' NEAREST
COMPENSATION INSURANCE/ CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) 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 subject to the Workers' Compensation Laws , !J9
AL COMPRESSOR,BTU a (/
APPROVALS _ DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Z�g
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU Q VALIDATION
hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full,force and effect. _J
l P15 119(47TOT.' s
License Number A Lic.Class
I CL
Contractor J f 1 Date ITEMS
ly
❑ I am exempt under Sec. Plan Check fee TOTAL 102.._7.5 U
B.&P.C.for this reason PERMIT ISSUING FEE
CHECK 102.75 5
Date: TOTAL FEE `'�i IGE °DO W
Signature f2
CD
OWNER-BUILDPLAN CHECK APPLICANT ER DECLARATION 't :: 24 -+
I hereby affirm that I am exempt from the Contractor's License Law NAME 1a
for the following reason (Section 7031.5, Business and Professions , j`u4r ; 1 If}�i�'2'
Code)' ADDRESS
❑ 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 k (ki at CVhA4i,p�
I, as owner of the property, am exclusively contracting MAIL tS rC�{�,V ��
with licensed contractors to construct the project (Sec- ADDRESS
tion.7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY pl. Q v TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097, Civ. C.). ^
ADDRESS 1� I lU
Lender's Name p
CITY fAI��L.S y TEL.NO.&I JS
Lender's Address STATE t,/ LIC. /J t�
I certify that I have read this application and state that the above LICENSE NO. iff CLASS 1.
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
proper foK-YspectiV p(urrpp_ose �/ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT''?/ �ATE ( _��