HomeMy Public PortalAbout5742AGNES AVE_Mechanical W0-rm.th' CI have COMPENSATION,DECLARATIONf corse APPLICATION FOR PERMIT
-affirm.thot I have a certificate of consent to self
insure„arya certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed withthe county building inspec- FOR APPLICANT TO FILL IN BUILDING ,` / e
tion department. (PRINT OR TYPE ONLY) ADDRESS 674,7_A Iel” /tela
Date Applicant LOCALITYCfr
NO. TYPE OP 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. PRO SED Y
the permit is for one hundred dollars ($100)or less.) .
I certify that in the performance of the work for which thiAIR HANDLING UNIT, CFM
s
permit is issued, I shall not employ any person in any manner
50 a5 10 beC me subject to the Workers'Compensation Laws. BOILER, BTU A �/► APPROVALS DATE INSPECTOR'S SIGNATURE
Q �� COMPRESSOR, BTU ROUGH
Date Applicants -
Zeq
NOTICE O PPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GITY n
LICENSED CONTRACTORS DECLARATION FLOOR BTU RAVC
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER. SUSPENDED UNIT /(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class
Z.
/rf �
Contractor Date
❑ U
I am exempt under Sec. LLI
U
Plan check fee IL
B.&P.C. for this reason PERMIT ISSUING FEE $ Q
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and `NAME ,.
Professions Code):
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will clothe work and
the structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
7 9f
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CI7Y �' TEL. NO. 7�3 �5 7 2 9 A
I hereby affirm that there is a construction lending agency for 0 0 0 0 o
the performance of the work for which this permit is issued CONTRACTOR #,
(Sec. 3097, Civ. C.). o - 51.50
ADDRESS
Lender's Name o o,0 5 1.5 0 C6
Lender's Address CITY TEL. NO. 0 2 2 8 6
I certifythat I have read this application and state that the STATE LIC.
Pp 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
upo the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent tote -