HomeMy Public PortalAbout6327 AGNES AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 31 8G'2 80) lL��l�'� ®��1 ®� PERMIT
I hereby affirm that I have a certificate of cou!0-it�-o pelf -
insure or a certificate of Workers'Compensation Insurance,or HkATING ENTILATING-AIR CONDITIONING
a certified c the�r�"of(Sec 3800,Lab C) r .�► p
Pohc11 , i U 7 Company 7-e_^o l� !e vur �e 1 -7 1 < ��rS c 6 a 3
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUI WING AND SAFETY
GCertified copy is filed with the 22Z
inspection '
d,'e��artment FOR APPLICANT TO FILL IN BUILDINGDate! Applicant 6 '(PRINT OR TYPE ONLY) ADDRESS 3 (// Gj /1 —es
LOCALITY (J 4
CERTIFICATE Or EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE P/� t �'✓ �� Com+
COMPENSATION INSURANCE NEAREST }
(Thisssection need not be completed if the work involved ABSORPTION UNIT' BTU CROSS ST N , tl
by the`permit is for one hundred dollars ($100) or less) - , DISTRICT NO PROCESSED BY O
I certify that in`the performance of the work for which this AIR HANDLING UNIT CFM /� — Ixa,
permit is issued, I shall not employ any person in any manner J0
so as to become subject to the Workers Compensation Laws BOILER BTU ` F-
- k+ APPROVALS DATE INSPECTOR SSh ATURE W
Date Applicant _ COMPRESSOR B°fu_�3_,CM_
_ ROUGH o'� � � (L
to
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall-be EVAPORATIVE COOLER VALIDATION
e
deemed revoked FURNACE FAU__ 3ppAVITY
LICENSED CONTRACTORS DECLARATION FLOOR —,BTU�OQM� !�
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT„' e
9 (commencing with Section 7000)of'Division 3 of the Bust WALL
ness and Professions Code, and my license is in full force and
effect - -
License Number 1f�_6 Z Lic Class d- Z�0 s I
Contractor _ nv4__.�__� �91
iDate_ — _
Oi am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above `
acting in my professional capacity (Section 7051; Bus '
mess and Professions Code) PERMIT ISSUING FEE $
Lic or Reg No Date - TOTAL FEE
HOME OWNER BUILDER DECLARATION r '" PLAN CHECK APPLICANT -
+ b hereby affirmthat I am exempt from the Contractor's NAME �_���_ � +
License Law forx the following reason (Section 7031 5, Busi _, ✓ t #b b Z1� A
ness and Professions Code) ADDRESS 6 § `
0 I, as owner of the property will do the work and the
structure is not intended or offered for sale (Section, CITY 7 ��� EL NO
OWNER
7044, Business and Professions Code) ry J 2 0 0 30 15 0
1, as owner of_the property, amsexclusively contracting a _ r ;-r + ,
with licensed contractors to construct the project' MAIL /�/ �1 a o e o 3 0,5 0 5
(Section 7044, Business and P�ofessioris Code) ADDRESS �,7 (/j N e S ' '
T_ple C° (oil o � g 0T_$.3
CONSTRUCTION LENDING AGENCY CITY �M ` 1 TEL NO �, .
I hereby affirm that there is a construction lending agency a r 5
for the performance of the work for which this permit is CONTRACTOR
issued (Sec 3097,Civ C) V
Lender's Name = ADDRESS ) I "
�O S C nir PQ Ct $ �it(!Ct ,
Lender's Address1 C
CITY Q SG TEL' NO
I certify that I have read this application and state that the STATE // LIC
above information is correct I agree to comply with all County LICENSE NO S, "b " CLASS
ordinances and State laws regulating Heating Ventilating and s
Air Conditioning, and hereb> authorize representatives of this SEE REVERSE rOR EXPLANATORY LANGUAGE r
County to enter upon the above mentioned property for
inspection purl )ses 5
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Signature of Permittee Date r _