HomeMy Public PortalAbout4859AGNES AVE_Mechanical WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Cpmpensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certi`ied copy thereof (Sec. 3800, Lab. C.)` 20-0046 DPW 9188
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C.r
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCES
the permit is for one hundred dollars ($100) or less.)
AIR HANDLING UNIT, CFM �c1
I certify that in the performance of The work for which this 5, \`
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR' SIGNATURE
Dat49Jc:^-62pplicaa� ��!✓����� COMPRESSOR, BTU4422R2 ROUGH + c
NOTICE TO APPLICANT: If, after makingthis Certificate of FINAL
VENTILATION SYSTEM
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAUVITY /P7 v/ fV
LICENSED CONTRACTORS DECLARATION FLOOR BTU (�
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
ZO o }
License Num�g:b� Lic. Class �` , 0
Contra or Date a —_;�` U09
❑ O
I am exempt under Sec.
Plan check fee u
B.BP.C. for this reason. H
Date: PERMIT ISSUING FEE $ Z
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):
ADDRESS �
I, as owner of the property, or my employees with 8
wages as their sole compensation,will do the work and ACCT°8
NO.
the structure is not intended or offered for sale(Section CITY TEL. '7307 a �.
7044, Business and Professions Code). OWNS J _+ °.ctE
t
I, as owner of the property, am exclusively contracting j ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL5150
CONSTRUCTION LENDING AGENCY ^� °f
C TEL. N ..C./ CHECK
51.50
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued LCONT2RACTOR �{-� �(�j� °Irl
(Sec. 3097, Civ. C.).Lender's Name {yy �y}��y ��}rJ0010— 001 10/ 5,189
Lender's Address ��13 _
E LIC. `7 !t AM r7°9
I certify that I have read this application and state that the LICENSE NO. Z� �_ CLASS C�v `fO'
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon t bov men ned p operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date es