HomeMy Public PortalAbout6006 AGNES AVE_Mechanical__ I I
j WORKKKI�R'S COMPENSATION DECLARATION 20-0046 DPW 9/89 y
76A364D ,APPLICATION FOR PERMIT LIME.: GREEN
I hereG>3 affirm that I have a certificate of consent to self insure,
or acertificatt of Worker's Compensation Insurance, or a certified
copy thtrbof tSec:3800 Lab. C.) HEATING -VENTILATING -AIR CONDITIONING
�
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ /gip /
• Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING (p (�
department. (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 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 rson in any manner so as to BOILER,BTU
become subject to the Workers'Com nsation wS.
/_n '�G COMPRESSOR,BTU D
�—te APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applic - � VENTILATION SYSTEM
NOTICE TO APPLICANT: If, iter making this Certificate 6f ROUGH Z+LZ6
Exemption,you should becomes bject to the Workers'Compensation
a EVAPORATIVE COOLER
provisions of the Labor Code, yo st forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALI_ D
1 hereby affirm that I am lHEATER
icensed under provisions of Chapter 9 SUSPENDED UNIT—
(commencing
(commencing with Section 7000) of Division 3 of the Business and : WALL ACC•T.10
Professions Code,and my license is in full force and effect.
3373 113.30
License Number Lic.Class D 1 ITEMS
Contractor j;"� Date / , TOTAL I I - 30 a
❑ Plan check fee CHANGE
K 118°30 0U
I am exempt under Sec. NAh1�E tl��l a:B.&P.C.for this reason C•
PERMIT ISSUING FEE $ o Q
Date: TOTAL FEE Q
Signature 0000—OGGO i 1/26/96 W
M
PLAN CHECK APPLICANT 447` 1 Al 11"°o 20 (n
OWNER-BUILDER DECLARATION V 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
Code): ADDRESS
❑ 1, 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). OyyNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agecy for CONTRACTOR c ,
the performance of the work for which this permint Is issued
(Sec.3097,Civ.C.).
Lender's Name ADDRESS / T
- CITY TEL.NO.
Lender's Address C/
I certify that I have read this application and state that the above LICE TATE SE NO. �?i7$7� CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
rep sentatwes of this County to enter upon the above-mentioned
pro ty for irlt,pection purposes.
—46-1;
,.(� SEE REVERSE FOR EXPLANATORY LANGUAGE
1-2-Z 4�
1.519N7
GNAT RE OF APPLICANT O AGENT DATE
0