HomeMy Public PortalAbout4833, 4825AGNES AVE_Mechanical (4) WORKERS'COMPENSATION DECLARATION CEA 8$C(2-80) \ p p� C QT S O N FOR [P C R MT
I hereby affirm that I have a' certificate of consent to self .
insure, or a certificate of Workers'Compensation Insurance,of HEATONG.e!E N71LAa QHG-AOR CONDOTPONUNG
a certified copy thereof(Sec. 3800,Lab.C.)
Policy No. Company
COUNTY OF LOS AfiIG('c0_(ES(�e BUOLDIING AND SAFETY
Certified copy is hereby furnished.
MCertified copy is filed with the county building inspection
department. 'FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR-EQUIPMENT FEE _
COMPENSATION INSURANCE NEAREST
CROSS ST. aw•-•-� G!/'� d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED B (,
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any persoKins ny manner �a� O
so as to become subject to the Wor ers' Co to Laws. BOILER, BTU 1—
,t� APPROVALS DATE INSPECTOR'S SIGNATURE LUL
Date _ Applicant _ �-� COMPRESSOR,BTU / S�� �� CL
ROUGH ''-p-c :; v a�
NOTICE TO APPLICANT: If, after makir this ertificate of VENTILATION SYSTEM FINAL -L 1 z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
i FURNACE: FA.U1 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT t�
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 ���� ic.Class
fs
Contractor— -S d ✓- a ll
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 OSSUON FEE $
Lic,or Reg.No. Date TOTAL FEF �/
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 TEL. NO. o
structure is not intended or offered for sale (Section CITY 3 2 6 2 A
7044, Business and Professions Code).
OWNER j # o 0 0 o 4 1
I, as owner of the property, am exclusively contracting
�''�
with licensed contractors to construct the project MAIL ^" ����� r
(Section 7044, Business and Professions Code). ADDRESS 0 .2_0,o 4'7.0 0
CONSTRUCTION LENDING AGENCY
CITY TEL. O. :o.o o 4 7t 0 0 60
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR ' �J r 2 O 1-_8 O
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS _i �
�.
Lender's Address CITY L.NCO.
I certify that I have read this application and state that the STATE Y� � LIC. r�
above information is correct.I agree to comply with all County LICENSE NO. 7.a , CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, anO hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to en po the above-mentioned property for
in a on f s
-fid
Signature of er 'ee Date