HomeMy Public PortalAbout4833, 4825AGNES AVE_Mechanical (8) WORKERS'COMPENSATION DECLARATION CEA 8( 2-Bo) \ p p L�OC A T p O N FOR P E R M �T
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,of HIZA704Z'G-VENTILATONG-AOR CONDOT0®`(r\1'ONG
a certified copy thereof(Sec. 3800,Lab.C.) 3
Policy No. Company
'Certified copy is hereby furnished. COUNTY OF LOS ANGELES BU[ILMNG AND SAFETY
Certified copy is,filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING zy
department: ADDRESS 14 G
Date Applicant (PRINT OR TYPE ONLY)
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. ! Gam/ O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE BY O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM,
permit is issued, I shall not employ any person in a manner J (' l ✓ O
so as to become subject to the Workers' Com 71V aws. BOILER, BTU
Date o/ Applicant -- COMPRESSOR,BTU n e7 e APPROVALS DATE INSPECTOR'S SIGNATURE a
N
ROUGH a �J'8o
NOTICE TO APPLICANT: If, after making isrtificate of VENTILATION SYSTEM _L Z
Exemption, you should become subject to the Workers' FINAL.
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be If Q
deemed revoked. FURNACE: FAL69--'/ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU C')
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT t
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code,and my license is in full force and
effect. ��� 1 7 y
License Number`�v• 13 Lic.Class
Contractor("
lam exempt from the licensing requirements as lama
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMOT OSSUING PEE v$
Lic.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
El1, as owner of the property, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code). OWNER 23261 A
El ' 71't
I, as owner of the property, am exclusively contracting
with licensed contractors to construct' the project MAI L / — � °I° °�° 4 1
(Section 7044,Business and Professions Code). ADDRESS 0{S 6r c
CONSTRUCTION LENDING AGENCY CITY TEL. O. .2 ° ° 417 0.0
I hereby affirm that there is a construction lending agency —� ;o o•o 4 7 0 0=
NTRACTOR
for the 'performance of the work for which this permit is CO
issued(Sec. 3097,Civ.C.). �.201 ,7-80 011 _80
Lender's Name ADDRESS aG ro=O
Lender's Address CITY 9061.NO. [[�
I certify that I have read this application and state that the STATE S LIC.
above information is correct.I agree to comply with all County LICENS NO. CLASS o�
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and he eby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter po t - bove-mentioned property for
ins ecti r purpos
ignature of Perin ee Date,