HomeMy Public PortalAbout4846 AGNES AVE_Mechanical_9/18/1989_COMPRESSOR, FURNACE, INLET/OUTLET WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
� I hs�ereby,affirm that 1 have a certificate of consent to self d
f ed copy thereofSecWorkers800 LoobC
nsa;on Insurance
;8 c�� r 76A364C HEATING VENTILATING AIR CONDITIONING
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+ roll MD-11 S�Company tslkI�r• rdA4 20 0046 DPW 9/88 `.
❑ Cdrtified copy is hereby furnished 4 µCOUNTY OF LOS ANGELES BUILDING AND SAFETY
i
EVE ertified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING
tion department ° ADDRESS V
Y T (PRINT OR TYPE ONLY)
Date -Applicant .&m d-Aov LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
i COMPENSATION INSURANCE CROSS ST Aft
U124-
(This section need not be completed if the work Involved by ABSORPTION UNIT BTU DISTRICT NO PRED BY
AIR HANDLING UNIT CFM
the pemit is for one hundred dollars ($100)or less) 6.,
I certifythat in the performance of the work for which this [�!(
permit is Issued I shall not employ any person in any manner
I so as to become subject to the Workers Compensation Laws BOILER BTU
APPROVALSDATE INSPECTORS SGNATURE
I y Date IY a Applicant C� i y COMPRESSOR BTU 11111100 ROUGH
dr
10-00 'gin
' NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
i.Exemption you should ,become subject to the Workers
} Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comp)Y with such provisions or this permit shall be deem
ed revoked FURNACE FAU GRAVITY �1
LICENSED CONTRACTORS DECLARATION FLOOR BTU (J
sl hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code and my license is in full force�and e1ffecctt
License Number S�7 0��- Lic Class C-2d '�J }
hiO
L'r_7- d _01► U
Contractor Date OC
❑ I
I am exempt under Sec 8
Plan check fee V
L B&P C fortthis reason A0 T s d
1 Date - PERMIT ISSUING FEE $ /10 15 �� ` in
73
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT 1 ITEMS
I hereby affirm that 1 am exempt from the Contractor s LicensePoo. TOTAL 4-;' 75
Law for the following reason (Section`7031 5 Business and NAME 0311 JJ
Professions Code) yo)g a� i (NECK 42 7c
❑ I as owner of the property or my employees with ADDRESS St/7 a '1'C IL._ I MME 00
wages as their sole compensation will do the work and CITY # TEL O
the structure is not intended or offered for sale(Section o S -L IS"
7044 Business and Professions Code) OWNER( 0000-Mi C��1 �Q
❑ I as owner of the property am exclusively contractingLrc 1
with licensed contractors to construct the ro ect'Sec MAIL ' r
tion 7044 Business and Professions Code)P l ADDRESS live_
1 AM 1..
CONSTRUCTION LENDING AGENCY CITYTEL NO
I hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit is issued CONTRACTOR �'
(Sec 3097 Civ C )
t ADDRESS
Lender s Name °
CITY C 1 V J "TEL N ,,,
Lender s Address
I certlf that I have read this a lication and state that the STATE I LIC /' _ 1 � a
Y PP LICENSE NO Q CLASS l.. .�(J
above information is correct 1 agree to comply with all County
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter
SIA
he aboyee pie ioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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S gnat a of Appl ca t o Age t Date Ir Os
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