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Home My Public Portal About5027-5029 SULTANA AVE_Mechanical__ OCOMPENSATION DECLARATION APPLICATION FOR PERMIT I heheby affirm that I have a certificate of consenito self ' insure or a certificate of Workers Comg9nsohan Insurance -7 C - 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 with the county building mspec FOR APPLICANT TO FILL IN BUILDING n tion department (PRIM OR TYPE ONLY) ADORESS Date Applicant LOCAIITY NO TYPE Of APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST (This section need net be completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO RNCESSED the permit Is for arra hundred dollars($100)or Ins) �^. I certify that in the performance of the work for which this AIR HANDLING UNIT CFM permit is issued I shall not employ any person in any manner so as to become subject to the Workers Co ho Laws BOILER BTU_ APIgtOYALs DATE itbRQ ATURP p_ 1 i Date�/2 n' SApplicant COMPRESSOR BTU ROUGH NOTICE TO APPLICANT If, after making this Certibcate of VENTILATION SYSTEM FINAL 19"7- ,y- Exemption you should become subject to the Workers' ' ' Compensation provisions of the Labor Code you must forth EVAPORATNE COOLER VALIDATION with comply with such provisions or this permit shall be I deemed revoked FURNACE FAU_GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 'I hereby off um that I am licensed under provisions of Chapter 9 HEATER SUSPEN N1T_ (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect — 0' d License Number ,r Lic Class , V K Contractor Dote O ❑ I am exempt under Sec i 2 6 6 5 A G 11. B 8P C for this reason Pl0n check fee . . . . . 8 WZ Dote PERMIT ISSUING FEE$ ( . . 21150 - Signature TOTAL FEE OWNER-BUILDER DECLARATION RAN CHECK APPUCANT '� I hereby affirm that I am exempt from the Contractor s License , Low for the following reason (Section 7031 5, Business and NAME - Pro essions Code) I as owner of the property or my employees with ADDRESS wages as their sole compensation will do the work and _ the structure is not intended or offered for sale(Section CITY TEL NO 7044 Business and Professions Code) - EJI as owner of the property am exclusively contractingOWNER with licensed contractors to construct the project (Set MAIL hon 7044 Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCY CITY - ,TEL pip - - 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 ) ADDRESS Lender s Name CITY _ - TEL NO - Lender s Address STATE LIC I certify that I have read this application and state that the 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 - upon a abo bone roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ Cy—12 "3-5- Signature of Applicant or Agent Date - - _ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I ". a certificate of consent to self insure, or a certificate of Workers Compensation Insurance7asx4c - - HEATING - VENTILATING - AIR CONDITIONING Or a certified copy thereof(Sec 3800, Lab C ) CE 818(REV ID/BI) - - Policy No Compony Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ T tion copy t filed with the county budding irope< FOR APPLICANT TO FILL IN BUILDING hon department - (PRINT OR TYPE ONLY) ADDRESS .7 Dote Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Pee - CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST t ABSORPTION UNIT STV DiSiaiCi NO EROCESSED er (This section me"not be completed If the work ImelYod by the permit Is for one hundred dollars ($1100)or Ins) ,lam r Q I certify that in the performance of the work for which this AIR HANDLING UNIT CFM permit is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws BOILER BTU AWROVALS DATE tivSPECTOR S SIGt TUK Dote pphcont �72/ COMPRESSOR BTU ROUGH NOTICE TO APPLICANT 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 VALIDATION with comply with such provisions or this permit shall be deemed revoked FURNACE FAU—GRAVITY— LICENSED GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that lam licensed under provisions of Chapter 9SUSPENDED UNIT_ I (commencing with Section 700D) of Division 3 of the Business HEATER WAIL and Professions Code and my license is in full force and effect / 9116 / l O License Number Uc Class \ l - ► U Contractor Dote - - - V ❑ _ I am exempt under Sec sir Plan check fee s B 8P C for this reason - N PERMIT ISSUING FEES () Z Dote Signature TOTAL FEE 0_ S OWNER BUILDER DECLARATION PIAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor s License , Law for the following reason (Section 7031 5 Business and NAME ('1 ANU Es L F Rt TO Professions Code) ❑ I as owner of the property or my employees with ADDRESS ;S'b ZR f'U- Sv t-TANA AV- Z 0 3 5 8 A wages as their sole compensation will do the work and �/ 1 �rs s s s s 8 the structure is not intended or offered for sale(Section Cin TE M C It / TEL Flo fps-`j` 3 4 7044 Business and Professions Cade) OWNER MA NU E L F e e 2 0 5 0 ❑ I as owner of the property am exclusively contracting �A f1TOdf•- with licensed contractors to construct the project (Sec MAILsJ(� Is's s 2 0 5 0 tion 7044 Business and Professions Code) ADDRESS SO 09 N S CONSTRUCTION LENDING AGENCY CRY TEL NO - - 0 3 1 0—8 3 1 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 ) ADDRESS Lender's Name ` CITY -TEL NO Lender s Address Iez STAR LIC I certify that I have recd this application and state that the LICENSE NO CLASS above info, tion is correct I agree to comply with all County ordinances d ate I ws relating to building construction, and hereb ut epres ntatives of this County to enter - upon t perry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ I Signature of Applicant or Agent