HomeMy Public PortalAbout6322 AGNES AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 t�
I hereby affirm that,l,have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMITFJ7
or a certificate of Worker's Compensation Insurance, or a certified " HEATING - VENTILATING-AIR CONDITIONING
c*,j fherebf(Sec.3800 Lab. C.) g
1i Lit
Policy No. Company 1 ,,A COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. iv
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. ` (PRINT OR TYPE ONLY) ,
y/ LOCALI
!, TY
Date `� ! Applicant„ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE (rst�
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. •. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU "•` �p ) �
become subject to the Workers'Compensation Laws. d 0� Ld LG�L�-Gl.GC�.
��' COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applica " VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z�
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ' DATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numbef� � � Lia Class
r
Date
_ZI 19(s CO I—
/70 , 's'w _I 0
Co
❑ I am exempt under Sec. Plan Check fee a:
B.&P.C.for this reason PERMIT ISSUING FEE$ �� 0
Date: TOTAL FEE ` U
_..a•-- III
ICL
Signature / I,'_%}=iL .ti ` ,-3(A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _.Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
j; y•t: :�
.for the following reason (Section 7031:5, Business and Professions
Code): ADDRESS
❑. I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. yf.^e3,t
structure is not intended or offered for sale (Section 7044, -
Business and Professions Code). OWNS I'j' s Y'
1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). y� ,tj "j
CONSTRUCTION LENDING AGENCY CITY TEL.N
hereby 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
ITY TEL.NO.
Lender's Address STATE LIC. Eb✓�'
certify that I have read this application and state that the above LICENSE N 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.URE OF APPLICANT OR AGENT DATE