HomeMy Public PortalAbout6009 AGNES AVE_Mechanical__ ION
DECLARAT
WOthat I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT• LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
ora certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
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 inspectionFOR APPLICANT TO FILL IN BUILDING61
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF.EXEMPTION FROM WORKERS' NEARESTCROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR r�
(This section need not be completed if the work involved by the MAP BOOK ,'U 0 PAGE 7 PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTO SIGNATURE
Date Applicant VENTILATION SYSTEM
-NOTICE TO APPLICANT: If, after making this Certificate of ROUGH -
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU' GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 DS SUSPENUNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL �
Professions Code,and my license is in full force and effect.
License Number Lic.Class ,
Contractor bate - V
❑ s iy
1 am exempt under Sec. Plan check fee cc
BAP.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE W
Signature CLCL
PLAN CHECK APPLICANT 0)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
NAME
fort )e following reason (Section 7031.5, Business and ProfessionsCode
i HL v —k' §
r.
ADDRESS sj"}
I, as owner of the property, or my employees with wages l'g`t
as their sole compensation, will do the work and the ayHEEC'•
P CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, - ; ej'
Business and Professions Code). OWNER
❑ I,.as owner of the property, am exclusively contracting MAIL _
with licensed contractors to construct the project (Sec- ADDRESS ;_I �!i�_t_i{ 1,
tion 7044,Business and Professions Code). 7
CITY TEL.NO. }r�fz F'
CONSTRUCTION LENDING AGENCY w 1, i
Ihereby 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
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I 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
representatives of this County to enter upon the above-mentioned
prop4_ _
or inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAOF APPLICANT OR AGENT DATt