HomeMy Public PortalAbout4849AGNES AVE_Mechanical (3) WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
reby affirm that I have a certificate of consent to self
re or a certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING
ertified copy thereof(Sec 3800 Lab C )r 76A364C
0 3O 9 Com an 'ITi TE rIA1 p 0046 DPW 9/88
P y COUNTY OF LOS ANGELES BUILDING AND SAFETY
C
ertified copy is hereby furnished
Certified copy Is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING f�-�
tion department (PRINT OR TYPE ONLY)
1 ADDRESS -fV � 4Vr
Date � Applicant LOCALITY ZY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE "�•�
CERTIFICATE OF EXEMPTION FROKERS NEAREST
r i r r COMPENSATION INSURA iABSORPTION UNIT BTU CE e r CROSS ST
(This section need not be completed if the work involved by DISTRICT NO IPR SSED BY
the permit is for one hundred dollars ($100) or less)
it ! 1 certify that In the performance of the work for which this AIR HANDLING UNIT CFM
F
permit is issued I shall not employ any person in any manner t
so as to become subject to the Workers Compensation LOWS ' BOILER BTU APPROVALS DATE INSPECTOR S S GNATURE
Date Applicant
i COMPRESSOR BTU - -37
ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should becomes subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
t with comp)y with such provisions or this permit shall be deem
ed revoked iA FURNACE FAU GRAVITY
t LICENSED CONTRACTORS DECLARATION x FLOOR BTU
V I hereby affirm that I,am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL ;
and Professions Code and my license is in full force and effect }
.f 9.3— — _aIL
.m License Number �Z / Lic Class "'"f"`_, _ _ _ ��'"'�- '�-''"'- -'�' ,�' _'.� --- -_ --- - - 0—
Contractor�ZbL� 42Y44 Date2-13--g u
T t 09
ElI am exempt under Sec U
s > Plan check fee
B&P C for this reason �
Date
PERMIT ISSUING FEE $ 5 Z
T `
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
I as owner of the property or my employees witfi ADDRESS 8
wages as their sole compensation will do the work and ACCT T
the structure Is not intended or offered for sale(Section CITY TEL NO � 7 2�
7044 Business and Professions Code) OWNER ZV
4I as owner of the property am exclusively contracting 1 I 90
' EMS
with licensed contractors to construct the project (Sec MAIL 4� L
tion 7044 Business and Professions Code) ADDRESS I UTAL 20.50
CONSTRUCTION LENDING AGENCY CITY y� �.� TEL NO CHECK 20
%1I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR � �
(Sec 3097 Civ C )
ADDRESS s i
Lender s Name
Lender s Address CITY TEL NO -101M I 9/13/'
I cern that I have read this application and state that the STATE LIC 4 17679 ! 1 AIS 9 07
certify PP LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction i °"
and hereby authorize representatives of this County to enter
upon the above mentio d property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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