HomeMy Public PortalAbout4833, 4825AGNES AVE_Mechanical (11) '7634
WORKERS'COMPENSATION DECLARATION CEA 86 8Ci2-80Y \ (fy tI"' L� C G=ET�O� N FOR !�ER�Vt} T
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEIa'd'ING_V ENTIL97ING-AOR CONDI-eIONING
a certified copy thereof(See. 3'800,Lab.C.) �p
PolicyCompan
Certified copy is hereby furnished.y COUNTY OF LOS ANGELES �i BUILDING AND SAFETY
Certified copy is filed with the county building inspection EORAPPLICANT TO FILL IN BUILDING ADDRESS
department. �3.a
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. (JZ�1-�jrJ CL .
O
by-the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS By U
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 i any manner /� O
so as to become subject to the WorkersC . s• n Laws. BOILER,BTU-'-- F-
- APPROVALS DATE INSPECTOR'S SIGNATURE W
Date j: �CApplicant ' 2-- COMPRESSOR,BTU—.! o[ �-
ROUGH-
NOTICE TO APPLICANT: If, after mak( t , Certificate of VENTILATION SYSTEM FINAL L(-F/ Z
Exemption, you should become subj ct.to the Workers'
Compensation provisions of the Labor Code; you must forth- - EVAPORATIVE COOLER �✓ VALIDATION
with comply with such provisions or this permit shall beio Of.
deemed revoked. FURNACE: FA GRAVITY
LICENSEDCONTRACTORSDECLARATION- FLOOR: BYU '�
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 5�'�7
ness and Professions Code, and my license is in full force and
effoet. g �j� Lie,.
License Nurnber.c7 5A— Li .Class
Contractorf
I am exem from the licensing requirements as I m a
P S 9 a ._
licensed architect or-a registered professional engineer Plan cheek fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT,ISSUING FEE $'
Lie.or Reg..No. Date TOTAL EEE'
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the.Contractor's NAME
Lieense Law for the following reason (Section 7031.3, Busi-
ness and Professions Code): ADDRESS
oI, as owner of the property, will do the•work and the CITY TEL. NO.
structure is not intended or offered for sale (Section 2 3 2 6 g A
7044, Business and Professions Code).
OWNER
DI, as owner of the property, am exclusively,contracting e3 Y i LJ D_ # m o 0 0 (i
with .licensed contractors to construct 'the project MAIL
(Section 7044, Business and Professions Code). ADDRESS` _ZZ-
2 0'0 4700
CONSTRUCTION LENDING AGENCY CITY, "tr •NO o - 47,0060
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR ( 2 Q 8
issued(Sec. 3097,Civ.C.). -
Lender's Name ADDRESS
Lender's Address CITY , _ ZV T NO
I certify that I have read this application and state that the STATI6!% LIC. .!
above information is correct.I agree to comply with all County LICE E NO. / CLASS Ci
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ent po he above-mentioned property for
ms ection pur e, i��
C,-/
Sig to
.7
of P m e Date