HomeMy Public PortalAbout5951 AGNES AVE_Mechanical__ ffifm that I_have'a TION DECLARATION t APPLICATION FOR PERMIT
,.-`P.�.ret'y affirm that I have a cei�iricate of consent to self '
insure, or a certificate of Workers'.Compensation Insurance,-' I
or a certified copy thereof'(Sec. 3800, Lab. C. 76A364C •HEAT•1'NG V-ENTIEA'T'ING- - AIR CONDITIONING
CE-818(REV. 10/81) j
Polis No. Com pony
"❑ Certified copy is hereby furnished. COUNTY OF.LOS ANGELES I BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department: ADDRESS �'5/
(PRINT OR TYPE ONLY)
Date Applicantj I LOCALITY
NO: TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 'tip
COMPENSATION INSURANCE I CROSS ST.
(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.)
\
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM I _ � J
permit is issued, I shall not employ any person.in any manner gpILERBTU
,
so as to become subject to the Workers'Compensation LOWS. _ APPROVALS DATE INSPECTOR'S SIGNATURE
' COMPRESSOR, B
'+ TU .Jul/ OGY� sn` I �J�� ROUGH
• D � Applicant-/1' _i _
FINAL
NOTICE TO APPLICANT: If, after making this.Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be I
deemed revoked. FURNACE: I FAUGR TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU . ( (-
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT t "
'(commencing with Section 7000) of Division 3 of the Business HE
WALL
and Professions Co.de,•and my license is in full force and effect.
CL
C
�-- Lic. Class ►
License Numb �� V�
Contr G Dat Q" 7
H
I am exempt under Sec. � � W
Plan check fee I CL
a
B.BP.C. for this reason I PERMIT ISSUING FEE $ l I J� Z
Date:
Signature
TOTAL FEE �J
'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): . I I , a
0 I, as owner of the property, or my employees with ADDRESS �rr7 a
wages'as their sole compensation,will do the work and j �''i •T
the structure is not intended or offered for sale(Section CITY TEL. NO.111 3307 30.507044, Business and Professions Code).
OWNER I
❑ I, os owner of the property, am exclusively contracting — 1 I TEMID
with licensed contractors to construct the.project (Sec- MAIL i.i .�-j/• . y i
tion 7044, Business and Professions Code). ADDRESS�J �I TOTAL
30 - 50
CONSTRUCTION LENDING AGENCY CITY L. NO �j C, 2 -f �E t
I hereby affirm that there is a construction lending agency for ��✓✓O� 4}{t •�i .r {.:t_
the performance of the work for which this permit is issuedCONTRACTOR , CHANGE .Lie
(Sec. 3097, Civ. C.). Aln
ADDRESS
Lender's Name
TEL. ^'1 ���. 00 00I 5/q•7/P
CITY I � - JVJ.
Lender's Address
STATE2 1 /• `2- LIC. r-^ v1 . Al! Lr26a�
I certify that I have read this application and state that,the - LICENSE NO� ,J (O( CLASS
above information is correct. I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter -
upon thAfa ov menyone-d perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date _ - -