HomeMy Public PortalAbout4833, 4825AGNES AVE_Mechanical WORKERS'COMPENSATION DECLARATION CEA 818(2-80) Q I� I— �C G�1T0N�l FO lf1S Ir RMT
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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 No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES MLDONG AHD SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLBGAi1IT_YO FILL 6N ' d
Date Applicant (PRINT OR TYPE ONLY) ADDRESS /T
• 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. O
by the permit is for one hundred dollars ($100) oI less.) DISTRICT N0. PROCESS gy C V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /� ►/
permit is issued, I shall not employ any person in any manner (1 J O
so as to become subject to the WSbkers Cotion Laws. BOILER, BTU
/ APPROVALS DATE INSPECTOR'S SIGNATURE V
Date--ZT���ApplicantLU
c . / COMPRESSOR, BTU �� y �p N
ROUGH
NOTICE TO APPLICANT: If, after makin t Certificate of VENTILATION SYSTEMS t 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
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR: BTU d%'"
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. ���y��j �a
License Number Y v � ! Lie.Class L- r
Contractor �! Va!C • ! � ® 1
0 1 am ex em t 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 ISSUMG ��� �
Lie.or Reg.No. Date TOTAL FEE
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 z 3 2'6 0 A
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). # o o,0 0 4 1
OWNER ,,�,
I, as owner of the property, am exclusively contracting �f , ��� '� �- fll,/��-� 2 2 7.O O
with licensed contractors Pr construct the , project MAIL — ,� o;o, I
Section 7044, Business and Professions Code ADDRESS � G� � /� � o
CITY TE .NO. 'a}o o27.000
CONSTRUCTION LENDING AGENCY /� '
I hereby affirm that there is a construction lending agency CONTRACTOR 2 0�1' 7 8 0
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS �e6 + LfjCi
Lender's Address CITY NO.
I certify that I have read this application and state.that the STATE
above information is correct. I agree to comply with all County I UCEN E NO.
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter u n e above-mentioned property for
ins cti n purp s
ignature of P itt Date