HomeMy Public PortalAbout5117AGNES AVE_Mechanical WQJCERS COMPENSATION DECLARATION C' 1 1l/30,�x APPLICATION FOR PERMIT
tnsurree'oratr Lertif cate off have
Workers srtComif tpensation e of Insurancent to f ✓v u '
or a certified copy thereof (Sec 3800 Lob C ) 76A364C C-7i0 — C(�iEATING --VENTILATING AIR CONDITIONING
CE 818(REV 10/81)
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 �p
tion department (PRINT OR TYPE ONLY) ADDRESS A6
Date �pplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
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 PROCESSED BY
the permit is for one hundred dollars ($100)or less ) /( 1:�2_1/
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM v o
permit is Issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws R/I / BOILER BTU APPROVALS DATE INS ECT S SIGNAT RE
Date Applicant Y SdCOMPRESSOR BTU 4d2O f M ROUGH D
NOTICE T APPLICANT If after making this Certi icate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers _
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRA TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business HEATER WALL
and Professions Code and my license is in full force and effect d
License Number LIC' Class V
0
Contractor__`__^� � Y
f �
v
I am exempt under Sec W
Plan check fee H
B&P C for this reason - PERMIT ISSUING FEE $ �9 2 7 A Z
D e
Signature TOTAL FEE # o o e o e 8
OWNER BUILD R DECLARATION PLAN CHECK APPLICANT ) • e 4 5 0 0
I hereby affirm that I am exempt from the Contractor s License 10.Law for the following reason (Section 7031 5 Business and NAME 0 0 0 4 ,5 0 0:C
Professions Code) 1=6 f /� �
❑ I as owner of the property or my employees with ADDRESS AV '
/u V O4,01 —88 S8
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section CITY (�'47yTEL NO
7044 Business and Professions Code) D „ -
OWNER
❑ I as owner of the property am exclusively contracting Ci L/t 1
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS f
AV
CONSTRUCTION LENDING AGENCY I CITY PIZ: TEL NO
I hereby affirm that there is a construction lending agency for loop.the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C ) v
ADDRESS ) LG` nAJ oe_� Y
Lender s Name
CITY ����,/�- TEL
Lender s Address t
STATELIC
I certify that I have read this application and state that the LICENSE NO CLASS
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 the abo endo ed roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A plcant or Agent