HomeMy Public PortalAbout6024 AGNES AVE_Mechanical__ WORKERS CI have cerci DECLARATION r APPLICATION FOR PERMIT
ere6y rofflrm that I have a certificate of consent to self
nsure or a.certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING
o,,Wcertifiecdcopy thereof (Sec 3800 Lab C ) CEA364C 618(REV 10/81) }
Policy No Company
❑ Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING ^
tion department (PRINT OR TYPE ONLY) ADDRESS (J
Date Applicant LOCALITY
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NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO OM WORKERS NEAREST j r
COMPENSATION INSUR CROSS ST
ABSORPTION UNIT BTU I DISTRICT T PROCESSED
(This section need not be completed if the wor olved by . .
the permit is for one hundred dollars ($100)or less
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which t
5 ( 0
permit is issued I shall not employ an person In any manner
so as to become subject to the Work s CompatlOMPRESSOR BTU ROUGH$n Laws � BOILER BTU APPROVALS DATE I ECiOR S SIGNATURE
k'
Date Applic nT
NOTICE TO APPLICANT If after m ng this Certificate of VENTI ON SYSTEM FINAL
Exemption you should become ubject to the Workers _
Compensation provisions of the Labor Code you must forth EVAPORATIVE LER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR —BT
01—
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER DED UNIT—
(commencing(commencing with Section 7000) of Division 3 of the Business WALL Y
and Professions Code and my license Is in full force and effect d
License Number Lic Classoil, ` ad
� V
f
Contractor Date 0 O
❑ I am exempt under Sec U
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Plan check fee VVV y
B 8P C for this reason PERMIT ISSUING FEE $ t )p Z
Date tel,/
Signature TOTAL FEE /
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT -2921 4 A
I hereby affirm that I am exempt from the Contractor s License , # o o ° 0 0 8
L w for the following reason (Section 7031 5 Business and NAME
P fessions Code) J ° ° 2050
1 as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and CITY TEL NO ° ° ° 2 0 5 0
the structure is not Intended or offered for sale(Section
7044 Business and Professions Code) NERo � ( 9-88
Elas owner of the property am exclusively contracting v� `
with licensed contractors to construct the project (Sec IL
RESS
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCYY TEL NO V��
I hereby affirm that there is a construction lending agency for '� ,
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097 Civ C )
- '
Lender s Name ADDRESS
CITY TEL NO
Lender s Address 'ate i 'a t
STATE LIC ti a t
I certify that I have read this application and state that the LICENSE NO CLASS
above Information Is correct I agree to comply with all County '
ordinances and State laws relating to building construction
and hereby authorize representa�vy
es of this County to enter
on jfie ab mento one o for Inspection purposes
It SEE REVERSE FOR EXPLANATORY LANGUAGE
IYI
gn ture of Applicant or Agent Date ` �`