HomeMy Public PortalAbout5729AGNES AVE_Mechanical (2) WORKERS COMPENSATION DECLARATION Y CEA 8 8 12 80) l��� ®i�l ®� U�%U �� J�
I hereby affirm that I have a certificate of consent to self 1 1
insure or a certificate of Workers Compensation Insurance or HEATING VENTILATING-Alba CONDITIONING U
a certified�/of +j9reo (jec /�jab C)
Policy No✓� /_O t C(ooipan_y'
/ " COUNTY OF LOS ANGELES / . `— BUILDING AND SAFETY
J- Certified copy is hereby furnished
❑ Certified copy is filed with t cow my builds r inspection
department� FOR APPLICANT TO FILL IN BUILDING
Date � Applicant_ _ � � (PRINT OR TYPE ONLY) ADDRESS
s > LOCALITY -1,6 kn)e? ll J
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE /
COMPENSATION INSURANCE NEAREST
CROSS STA �e < d
R
(This section need not be completed if the work involved ABSORPTION UNIT BTU p
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCESSED 1Y U
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM ,— 0 - /
permit is issued I shall not employ any person in any manner �5 (((oJJJJY O
so as to become subject to the Workers Compensation Laws BOILER BTU
APPROVALS DATE INSPECTOR S SIGNATURE U
W
Date Applicant COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM r FINAL r �r
Exemption you should become subject to the Workers _
Compensation provisions of the Labor Code you must forth VALIDATION
w•th comply with such provisions or this permit shall be EVAPORATIVE COOLER
deemed revoked FURNACE FAU GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU L
I hereby affirm that I am licensed under provisions of Chapte'r HEATER SUSPENDED UNIT Q'
.9 (commencing with Section 7000) of Division 3 of the Busi i/WAALLL Gam)f
Hess and Professions Code and my license is m full force and / � 1�!N o1J
effect
License Num rV
C/ Lic Class C^ J
Contractor_ L�/ llete
❑ /
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
loess and Professions Code) PERMIT ISSUING FEE $ so
Lic or Reg No ri DateTOTAL FEE 3-3
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT r
n �
i hereby affirm that I am exempt from the Contractors NAME
License Law for the following reason (Section 7031 5 Busi s
ness and Professions Code) ADDRESS h `
❑ I as owner of the property will do the work and the a r
structure is not intended or offered for sale (Section CITY TEL NO
7044 Business and Professions Code) OWNER _ ;-92230A
❑ �R />/I as owner of the property, am exclusively contracting �y VVV i i
with licensed contractors to construct the project a MAIL # o oto 0 o 8
(Section 7044 Business and Professions Code) ADDRESS �� 2,- - 33,50
CONSTRUCTION LLNDING AGENCY CITY TEL NO �ll_4e,�,/�
I hereby affirm that there is d construction lending agency / /—�`r tetetio 3 7j 5
for the performance of the work for which this permit is CONTRACTOR 0 '
,issued (Sec 3097 Civ C) _ _Qd 5—v— — 1209-81
Lender s Name ADDRESS
Lender s Address R CITY 'i�I TEL NO a
I certify that I have read this application and state that the STATE e"
above information is correct I agree to comply with all County LICENSE NO _ CLASS
ordinances an+ State vs regulating Hbating Ventilating and e
Air Co ditio g a d ereby au `iorize representatives of this SEE REVERSE FOR EXPLANA'T'ORY LANGUAGE
Cou y to me pon the aF r mentioned property for
In er .or u ses ^
Signatu e o Permittee Date _ r