HomeMy Public PortalAbout5022 SULTANA AVE_Mechanical__ WORKER BCOMPENSATION DECLARATION 2D.OW DPW 9189 APPLICATION FOR PERMIT �O�E GREEN
7SA38aC
I hereby affirm that I have a certificate of consent to self Insure
or a certificate of Worker a Compensation Insurance or a certified 'HEATING-VENTILATING -AIR CONDITIONING
copy thlreof(Sec 3800 Lab C)
Policy No r Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ,
Cemfu d copy b hereby furnished
❑ Candid copy fa filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
department (PRINT OR TYPE ONLY) ADDRESS
GDate Applicant NOTYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE, . ABSORPTION UNIT BTU
(This to ctlon need not be completed N MAPASSBO
the work Involved by the OOi
permit Is for We hundred dollars($100)or Mu) AIR HANDLING UNIT CFM MAR BOOK
PAGE PARCEL
oisrwcr ro moan®er
I certify+that in the performance of the work for which this permit '
is Issued I shall not employ any person In any manner so as to BOILER BTU �O L
become Subject to the Workers Compensation Lowe 0
` COMPRESSOR BTU
.rrmvus on eaxuuTURs
Date Appkmnt VENTILATION SYSTEM /
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compen saoon EVAPORATIVE COOLER
prowalons of the Labor Code YOU must forthwith comply with such FINAL
prove none or this permit shell be deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU _ VACID4TION
I hereby affirm that I em licensed under provisions of Chapter S I HEATERSUSPENDED UNR_
(commencing with Section 7000) of Division 3 of the Business and WALL '
Professions Code and my[team a is in full force and effect _
License Number Lie Clme
y
Connecta Date Poo. CL
❑ I em exempt coax sec Plan check fee 8
Q
B aP C for this reason PERMIT ISSUING FEE$ OW 0
Date TOTAL FEE W
Sgnature G.
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I ern exempt from the Contractor a License Lew NAME r
for the following reason (Section 7031 s Business and Professions , Fig CT.i
e) ADDRESS _
I as owner of the property or my employees with wages "'U7 ��'•l�l=
as their sole compensation will do the work and the CTT' TEL NO 1 ITBO:
structure is not intended or offered for sale (Section 7044
c
Businessend Prolesslons Cotle) vMEA D j(Ij AL `} _t � dd
❑Y I as owner of the property am exclusively contracting LIrr t,
With licensed contractors to construct the project (Sec MAILRE59 �HEU,
tion 7044 Business and Professions Code) CITY / TEL NO MANGE •c1c.
CONSTRUCTION LENDING AGENCY 1. _
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit s issued
(Sec 3097 Civ C) ADDRESS - �il�l[n—lUtl1 7
Lender a Nemo
CITY TEL NO
Larder a Address STATE UC
I certify that I have read this application and state that the above LICENSE NO CLASS ,
information of correct I jp "s
mply with all County ordinances
end State lawn relabng tonstruction and h a ooze '
repreeente oft Cter upon the toned
r M f 1 n SEE REVERSE FOR EXPLANATORY LANGUAGE
oR Te