HomeMy Public PortalAbout5729AGNES AVE_Mechanical WORKERS COMPENSATION DECLARATION CEA 8 8 (2 80) API P UC A T I®1 tl FOR P E R NVa T
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING AIR CONDITIONING
d certified copy thereof(Sec, 3800 Lab C)
'fl
Policy No WCW 309`35p5i8 West American Ins /rte �,
Certified copy is hereby furnished
COUNTY OF LOS ANGELES � BUILDING AND SAFETY
lJ Certified copy is filed with the county building mspectio
P FOR APPLICANT TO FILL IN BUILDING
Date�r'�r jartm �n i.� (PRINT OR TYPE ONLY) ADDRESS 5729 Agnes
t/ 2 pplicanY —
LOCALITY Temple Clt i
CERTIFICATE OF EXEMPTION FROM'AV KERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE'
p c
COMPENSATION INSURANCE NEAREST ~ , >_(This section need not be completed"if the work involved ABSORPTION UNIT BTU y CROSS ST CL
bythe permit is for one'hundred doUars ($100) or less) � O
DISTRICT NO PROCESSE BY i 0I certify that in the performance of toe work for which this AIR HANDLING UNIT CFM S,a J �� O
permit is issued I shall not employ any person m any manner `
so as to become subl'ect to the Workers Compensation Laws BOILER BTU
APPROVALS DATE"'
AT INSPECTORS SIGNATURE IU
Date Applicant LI
COMPRESSOR BTUROUGH '� CL
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM
Exemption you should become subject to the Workers
FINAL
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VA'_FURNACE FAU GRAVITY—
LICENSED
with comply with such provisions or this permit shall be
deemed revoked
i
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensedrunder provisions of Chapter HEATER SkJaPENDED UNI i
9 (commencing with Section 7000) of Division 3 of the Busi WAL �! b
ness and Professions Cr de and my license is in full force and
effect ,� of G �y / ,
License Numbed ] 7 Lic Ciass CiT (�f sd ZV
}
Contractor Date
F1i am exempt from tl a licensing requirements as I am a
licensed architect or a registered professioDal engineer Plan check fee 25%of above y
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE $ Q
r s
Lic or Reg No Date TOTAL FEE 0
HOME OWNER BUILDER.DECLARATION '' PLAN CHECK APPLICANT # z "
I hereby affirm that I am exempt from the Contractors, NAME
License Law for the following reason (Section 7031 5 Busi ( '
ness and Professions Code) ADDRESS 4oi� x 2 0 6 0
I as owner of the property will do the worK and the CITY TEL NO s ° 1 4
structure is not intended or offered for sale (Section r s I 0 0 5—8 3
a7044 Business and Professions Code) 01ISN E R
Ias owner of the property am exclusively contracting
with licensed contractors to construct the project / MAIL
(Section 7044 'Business and Professions Code) L ADDRE,.S �7— 9
CONSTRUCTION LENDING AGENCY CITY
T NO ��
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec 3097 Civ C) —
47
Lender's Name ADDRESS
Lender s Address �r �/ � p�,�, (,� Q 4
CIT�vL�J�r/✓""� TEL NO /
I certify that i have reid this application and state that the ST TF q LIC '
aoove information is correct 11 agree to comply with all County LICA +SE NO � _7L9d CLASS _L2,7—W
ordmdnees and State laws regulating Heating Ventilating and
Air Conditioning and hereby authorize repr entatives of this } SEE REVERSE FOR EXPLANATORY LANGUAGE — v
Coi r y to enter upon the above merit nod property for ti
m ct �n�rp ses
Signature of Permittee Date