HomeMy Public PortalAbout5112AGNES AVE_Mechanical WOKifi.Ea� CC til ET�bi.I iON DECLARATION CEA 818(2 80) A P Ir ISS BC A T�ON FOR Ir E R M ff
I hereby affi in that I hdvL a i.ertificate of consent to self
insure or a cerSiflcate of Wor^ers GDmpensation Insurance or HEATING-VENT ILATING-Al R CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
Policy No Company
El Cerfified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the counSy building inspection BUILDING
department FOR APPLICANT TO FILL IN ✓ /'.
Date Applicant '(PRINT OR TYPE ONLY) ADDRESS
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 d
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCESS D Bt UO
1 certify that in the performaaue of the work for which this AIR HANDLING UNIT CFM �`
permit is issued I shall not e-nploy any person in any manner - Ir
so as to become subject to the Workers Compensation Laws BOILER BTU 0
�, ^�f� / c f� APPROVALS DATE INSPECTOR S SIGNATURE V
D✓ �! v�npplicant `-'!R�L6 COMPRESSOR BTU f/ �f7 0 ROUGH d
j NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM rn
Exemption fou should become subject to the Workers FINAL —��- �/ Z
Compensation provisions of the Labor Code you most forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU
" LICENSED CONTRACTORS DECLARATION l FLOOR BTUs
1 hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commenemg with Section 7000)of Division 3 of the Busi WALL
ness and Professions Code and my license is in full force and
effect 2J
License.Numbei ,JZiic Class �^
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $ �e2
Lic or Reg No Date TOTAL FEE J
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby, affirm that I dm exempt from the Contractors NAME
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code) ADDRESS
I as owner of the property will do the work and the TEL NO
structure is not intended or offered for sale (Section CITY
7044 Bu,iness and Professions Code) OWNER F r 3 4,5 9 A
I as owner of the property am exclusives contracting # 0!0*'*
m 8
P P Y Y g o oio 0 0
with licensed contractors to construct the project MAIL
(Section 7044 Business and Professions Code) ADDRESS l ?ko l0 3 a 5 0
CONSTRUCTION LENDING AGENCY CITY TEL N/7/(/- y
I hereby affirm that there is a construction lending agency ° °cO 3 5 0 v
for the performance of the work for which this permit is CONTRACT �t,/,��� `.
issued(Sec 3097 Civ C) — 7 i 0 313 1 r*8 2
Lender s Name ADD RE SS.Cr & —�
Lender s Address CITY TEL h�7 O��s
I certify that I have read this application and state that the ST TE / LIC Z 0
above information is Correct I agree to comply with all County LICENSE NOIZ [� Z CLASS
ordinances and State laws regulating seating Ventilating and
Air Conditioning and hereby authorize representatives of this SEE REVERSE rOR EXPLANATORY LANGUAGE
County to enter upon the, above mentioned property for
u �Kitu_,e'o
pu � es
�J
4g. f Permittee Date