HomeMy Public PortalAbout4910AGNES AVE_Mechanical (2) WORKERS COMPENSATION DECLARATION CEA 818(2 80) APPLICATION FOR PERMIT
I hereby aff%rm that I have a certificate of consent to self
insure gr a rLrhAcateof Workers Compensation Insurance or HEATING-VENTILATING-All CONDITIONING
A certified copy thereof(Sec 3800 Lab C)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
11 Certified copy is hereby furnisheq
department cdpy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING �j
department (PRINT OR TYPE ONLY) ADDRESS �—Ali-A��
Date Applicant `
i NO TYPE OF APPLIANCE OR EQUIPMENT eFEE LOCALIT ,p
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE NEAREST1CROSS ST / ` a
(THIS SeCtiOII need not be completed if the work involvedABSORPTION UNIT BTU Com/ / J�
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROs 'D BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT-CFM �
permit is Issued I shall not employ any 'son in any manner �/
so as to �ecoire subject to the`'Porker omv sa`ion Law, BOILER BTU �/� d 1—
DateY/)��. APPROVALS -DATE INSPECTOR S SIG URE W
/x/.1-1 pp>icant _ _ 7 _ COMPR:SSOR BTU ROUGH r N
NOTICE TO APPLICANT If iter making this CertifiLate of VENTILATION SYSTEM Z
Exemption you should bec(rqe SNject to the Workers FINAL
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER
with comply with sach provisions or this permit shall be VALIDATION
deemed revoked V. FURNACE FAUBTU GRAVITY—
LICENSED
RAVITY LICENSED CONTRAC'T'ORS OECLAR ATION
I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
/(commencing with Section 7000)of Invision 3 of the Bust WALL Y
/ness and.Professions Co4e and my ltgense is in full force and t
effect -
Licensl3iber 73 Lic Class to S
Contractor Date ;
I am exempt frond the licensing requirements as I am a R
licensed architect or a registered professional 4ngineer Plan check fee 25%of above
acting tri my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE$ sQ
Lic or Reg No Date I TOTAL FEE
HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that i am exempt from the Contractor's NAME
License Law for the following reason (Section 7031 5 Bust
ness and Professions Code) ADDRESS , - - —43 1 812 1 A
t as owner of the property will do the work and the
structure is not)intended or offered for sale (Section CITY TEL NO - '# •!o o •1. 8
7044-Business and Professions Code) I
QOWNER
I as Owner of the property am exclusively contracting h 2 °Y• 313 5 0�
with licensed contractors to construct the project MAIL
(Section 7044 Business and Professions Code) ADDRESS 9�� G! S • o)01 3 3 50H
WNSTRUCTION LENDING AGLNCY CITY TEL NO.2,r S-4-703 +0 2f8-8 2
I hereby affirm that fhere is a construction lending agency r j
for the performance at the work for which this permit is CONTRACTOR�G
issued(Sec 3097 Giv C)
Lenders Name ADDRESS r h
Lender s Address CITY�_l TEL NO
1 certify that i have read this application and state that the STATE LIC �
above information is correct 1 agree to comply with all County LICENSE NO CLASS
' ordinances and State laws regulating Heating Ventilating and
Air Conditioning and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County t enter upon the above mentioned property for
uet"or w potse� %/✓J
�, p na �
re of
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