HomeMy Public PortalAbout4833, 4825AGNES AVE_Mechanical (6) WORKERS'COMPENSATION DECLARATION CE81a 801 A3864Cn n n �� /tel UOO p'�l FOR 11� ��%U ��
I hereby affirm that I have a' certificate of consent to self G�1 V_ lIJ ( 1
ER
insure, or a certificate of Workers'Compensation Insurance,or b[ Q4B��4�j[ (��O�Ga�B(�9�-Ga0fa2 ��Ub®850®G�BL`�7C�
a certified copy thereof(Sec. 3800,Lab.C.)
Policy Company. COUNTY OF LOS ANGELES7 ,t 18W LMNG AND SAfF(ETY
El Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection ADDRESS TO �BB_d BfU. BUILDING
�O7
department. l�3—
Date Applicant (PRINT OR TYPE ONLY) —
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE- _G-
.COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS.ST. 10 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY U
'IR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person iA
n any manner U 0
so as to become subject to the Work rs' Compels n aws. BOILER, BTU 0
Date/ - 15 Applicant e?1 APPROVALS DATE INSPECTOR'S SIGNATUREI LU
U
pP Z COMPRESSOR, BTU �O' ROUGH 7-.;L9-ko CL
NOTICE TO APPLICANT: If, after making t ertificate of VENTILATION SYSTEM FINAL _i 14.1 Z
Exemption, you should become subject the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER, i VALIDATION
with comply with such provisions or this permit shall be f/�(�
deemed revoktd.
LICENSED CONTRACTORS DECLARATION FLOOR: FAUB U GRAVITY
—
LICENSED �
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. /1
License NumberL � Li .Class
i
Contractor 69_/ aq 6
❑ I am exemptfrom the licensing f' requirements as I am a
g
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). PERMBT QSSOIBUO F-EE $
Lic.or Reg.No. Date TOTAB_'FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I
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 ;9 3 2 6,7 A
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). #OWNER 0.0-o 0.41
❑ I, as owner of the property, am exclusively contracting •tU �il�U'M �v 2 ° - 4700
with licensed contractors to construct the project MAIL J
(Section 7044, Business and Professions Code). ADDRESSb 0 0 0 (j 7,0 0 v
CONSTRUCTION LENDING AGENCY CITY TEL O.
I hereby affirm that there is a construction lending agency .1 2 0'1' 8 0
for the performance of the work for which this permit is CONTRACTOR a
issued(Sec. 3097,Civ.C.). —
Lender's Name ADDRESS; L ry,f q
Lender's Address C1TY S /6 /r�?ZZ.'
I certify that I have read this application and state that the STAT LIC.
above information is correct.I agree to comply with all'County L10EN ENO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter p n t bove-mentioned property for
ins Pct' i purpo
* Z 2% C
ignature of Per itt Date