HomeMy Public PortalAbout4831AGNES AVE_Mechanical (2) WORKERS'COMPENSATION DECLARATION CEA SIB (2-80) �lf—1r UC AT M N FOR PE R M M
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEArTONG-W..ENTILATING_AIR C®N®0 ONII`(r\G
a certified copy thereof(Sec. 3800,.Lab.C.)
Policy No. Company -�-
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUOLOING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT T TO FI LL INiN
(PRINT OR TYPE ONLY) ADDRESS %��7
Date Applicant !!
LOCALITY
CERTIFICATE.OF EXEMPTION FROM WORKERS' NO. ' TYPE OF APPLIANCE OR EQUIPMENT FEE _
COMPENSATION INSURANCE NEAREST
CROSS ST... d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS-D BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFNI `
permit is issued, I shall not employ any person in any manner tJ O
so as to become subject to the Workers' ) ation Laws. BOILER,BTU
r—,
APPROVALS DATE INSPECTOR'S SIGNATURE IU
Date Applicant Applicant eGRc. COMPRESSOR,BTU G ROUGH
N
NOTICE TO APPLICANT: If, after ma ng .his Certificate of VENTILATION SYSTEM �Z[ �'/ Z
Exemption, you should become subject to the Workers' FINAL -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
comply with such provisions or this permit shall be ®CD
deemed revoked. i ZL
FURNACE: FAU GRAVITY '
LICENSED CONTRACTORS DECLARATION FLOOR: BTU T
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
ness and Professions Code, and my license is in full force and
effect.
License Number A5 65__ Lic:Classes
6.
Contractor Cyt�Ce�<% ✓r� '� ��j
I am exemp 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). PERMOT MUING EEE
Lie.or Reg.No. Date TOgAL EES
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
I, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section '23266A
7044, Business and Professions Code). -
OWNE # 0'0 to o /,)
I, as owner of the property, am exclusively contracting _ S L e"y �C ,
with, licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 7c/N 2 0'0 4.7 Q 0
CONSTRUCTION LENDING AGENCY CITYY_�� '6�r+e TEL.. O, 0 0 0 4 7.Q Q U
I hereby affirm that there is a construction lending agency ,
for the performance of the work for which this permit is CONTRACTOR e Q ' 2 0 4r-8 Q
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
7,7t_A/. . v
Lender's AddressCITY v - fEL.NO. �
I certify that I have read this application and state that the STATE t LIC. yj
above information is correct.I agree to comply with all County LICEN555SS5E NO. �� / CLASS bs 0—
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to a er u the above-mentioned property for
in a .ion pr o
Signature o er tee. Date