HomeMy Public PortalAbout4913AGNES AVE_Mechanical -ter---- - �-
WORKER SCOMPENSATION DECLARATION 200048 DPW 9/89 APPLICATION FOR PERMIT Lim
E GREE I `
I hereby affirm that I have a certificate of consent to self Insure 76A384C M
Or a certificate of Worker s Compensation Insurance or a certified HEATING-VENTILATING AIR CONDITIONING Y
copy thereof(Sec 3800 Lab C)
Policy No Company
❑ ' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS , BUILDING AND SAFETY DIV
Certified copy Is hereby furnished � y I
ElCertified copy Is filed with the county budding insp9
ADDRES /ection FOR APPLICANT TO FILL IN , BUILDING
PRINT OR TYPE ONLY) T S �+ I
department t ( Y)
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Date Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE e- Y
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
r� COMPENSATION INSURANCE a ABSORPTION UNIT BTU I CROSS O t ! ro
(This section need not be comp the work involve b the , , ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred doll s($100 or ess) / AIR HANDLING UNIT CFM DISTRICT NO 7 PROCESSED BY
certify that in the perform ce of the �ro for which t ermlt e '
is issued I s4APPL
pl any perso n en %mann/e ' as to y A T °
Y BOILER BTU �0
become sub actor rs Co pens ion Laws
9
COMPRESSOR BTU
APPROVALS DATE INSPECTOR S SIGNATURE
DateApplicant VENTILATION SYSTEM
NOTICE TO T If after aking this Certific of ROUGH
Exemption you should become subject to the Workers Comp anon
provisions of the Labor Code you must forthwith complyrw such EVAPORATIVE COOLER f FINAL
provisions or this permit shall be deemed,revoked FURNACE FAU GRAVITY ^r o i
f LICENSED CONTRACTORS DECLARATION FLOOR BTU i VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED NIT
HEATER ,
(commencing with Section 7000)of Division 3 of the Business and , WALL
Professions Code and my license is in fu
Vbrce and effect
3r,Llcense Number Li Class C^w I c
T { Y , , ,' t
Contractor l I Ia.te 93 rr O
Plan check fee r
❑ ' U
I am exempt der Sec { Q
Y
B&P C for this reason i PERMIT ISSUING FEE$ O
_ Date J '{ %% „ TOTAL FEE gg 00
Signature a
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT t t co
f I hereby affirm that I am exempt from therc- k CA
License Law NAME L
for the following reason (Section 7031 5 Business and Professions A r a J
h
Coe ADDRESS / / H a�e /y U�
I as owner of the property or my employees with wages " h{
as their sole compensation will do the work and the CITY,— ' a /' TEL NO yrf rrli a t ~i
structure Is not intended or offered for sale (Section 7044
I T _
Business and Professions Code) ; OWNER �,p
IE] I as owner of the property am exclusively contracting MAIL i A Y 1 n +
with licensed contractors to construct the project (Sec ADDRESS ' + `� j l l k T ® 00 a
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY } CITY - TEL NO i f r-E
Ihereby affirm that there is a construction lending agency for f
the performance of the work for which this permit is Issued CONTRACTOR Poo.Poo.
(Sec 3097 Civ C) IJ V (.90
ADDRESS,14 U
Lender s Name J G
' CITY t Je rst �[* TEL NO �IY7)U' r q 8 ; _I�I{I-Lltti{�
Z a t
Lender s Address STATE LIC - ` -Cti"-
I certify that I have read his application and state that the above LICENSE NO CLASS i C_ Z
/fo
rmdo is correct ree to comply with all County ordinances
andawa relator' building nst coon and hereby authorize ativesof A ounty to ent upon the above mentioned
Op for insp n purpos v SEE REVERSE FOR EXPLANATORY,LANGUAGE
f M •.- i
"SIGNATURE OF A PL CANT OR AGE DATE r