HomeMy Public PortalAbout4831AGNES AVE_Mechanical WORKERS'COMPENSATION DECLARATION CEA 81 8 (2-80) G=,1 P U-" UC A T M N FOR P E UIS MY
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
Policy rtified copy is hereby furnished.Company
Certified COUNTY OF LOS ANGELES �� BUILDONG AND SAFETY
Certified copy is filed with the county building inspection
department. FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) _
ESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the Work involved ABSORPTION UNIT, BTU—, CROSS ST. _ Q yL✓Lf 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY 0 .
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cr
permit is issued, I shall not employ any person in any manner +� !t� 0
so as to become subject to the Workers' ro �p sation Laws. BOILER, BTU—
APPROVALS Applicant Jr_ .fi Cd!j APPROVALS DATE INSPECTOR'S SIGNATURE w
Date S_/ pp COMPRESSOR,BTU.--/_ �D - N
ROUGH
NOTICE TO APPLICANT: If, after ma: ng Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be L O,9G
deemed revoked. FURNACE: FAUo GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU 42 0
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT +
9 (commencing with Section 7000) of Division 3 of the Busi- WALL 'J2
ness and Professions Code, and my license is in full force and
effect.
License Numb e d_9 Lic.Class_ C'-c2 0
�p j
Contractor °cS
I.
G"Y
I 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-
iness and Professions Code). PERMIT OSSUWG EEE $ '7
Lic.or Reg.No. Date TOTAL E(EE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness•and Professions Code): ADDRESS
1, as owner of the property, will do the work and the CITY TEL. NO. ;23 2 6.5 A
structure is not intended or offered for sale (Section
7044, Business and Professions Code). # 0.0 0 0.4
OWNER • .
I, as owner of the property, am exclusively contracting 2 o I'o (�']
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS _ j� 1 �✓(,' 6 _�itL
47.00
it
CONSTRUCTION LENDING AGENCY CITY
I hereby affirm that there is a construction lending agency a G — 20,1=80
for the performance of the work for which this permit is CONTRACTOR S , Gaa
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS 7��. +, f 0i- f�
Lender's Address CITY TL.NO. / r
I certify that I have read this application and state that the STATE LIC. e10`�D
above information is correct.I agree to comply with all County LICENSE NO:J! CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ent the above-mentioned property for
inspe ion pJure e
Signature of P -mi a Date