HomeMy Public PortalAbout6003 AGNES AVE_Mechanical__ W,Othat I S COMPENSATION DECLARATION 76A34f3 DPW 9,69 APPLICATION FOR PERMIT LIMEI hergby,affirm that I have a certificate of consent to self insure, 76A364C GREEN
or a certif ofjS c 13800 Lab.
Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.j
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
department. - (PRINT OR TYPE ONLY) ADDRESS (r7
Date Applicant LOCALITYNO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
(This section need not be completed if the work involved by the ASSESSOR
E PARCE
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGLolsTRlcr No. PRoeesseD BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �� b
become subject to the Workers' Compensation Laws. , Do U d
COMPRESSOR,BTU e6o. DO D
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM -
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH � }
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked.. FURNACE: FAU G YDI1U
LICENSED CONTRACTORS DECLARATION FLOOR BTU O i9t� VALIDATION r
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL
Professions Code, and my license is in full force and effect.
License Number Lic.Class
Contractor Date w Dv
0
❑ I am exempt under Sec. Plan Check fee 0
B.&P.C.for this reason PERMIT ISSUING FEE p C)
Date: TOTAL FEE 3 O W
Signature IZ
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME, ,
for the following reason (Section 7031.5, Business and Professions _t f
ADDRESS s -�
I,,as owner of the property, or my employees with wages i =.-.'_ ,T ' ,
as their sole compensation, will do the work and the CITY TEL.NO.
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structure is not intended or offered for sale (Section 7044, { - -_-• '' n
Business and Professions Code). OWNER L ��� r �j� s,1
Awt$ I, as owner of the property, am exclusively contracting MAIL �(� v —
FF with licensed contractors to construct the project (Sec- ADDRESS C) I_i _ d p
tion 7044, Business and Professions Code). �T
CONSTRUCTION LENDING AGENCY cl!! 1 Q ; TEL*
i��j
�� .
I hereby affirm th there is a construction lending agency for. CONTRACTOR s=
the performance f the work for which this permit Is issued ,
(Sec.3097,Civ.C.. 1. V
ADDRESS
Lender's Name
�P�/
CITY TEL.NO. .:_
:a I_r `fig1,
Lender's Address STATE LIC. -
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
represent IAofh� County to enter upon the above-mentionedpropes. i SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATVFV.PFPVRPTTOR AGENT DATE