HomeMy Public PortalAbout5057 SULTANA AVE_Mechanical__ WORKER I have a certificate of
7BA364�''a/B° APPLICATION FOR PERMIT_ �I�tl1E GREEN
I hereby affirm that I have a certdwete of consent to Bell insure �C [j
or efertifcald'of Worker a Compensation Insurance or a certdled HEATING-VENTILATING-AIR CONDITIONING I'
copy therdb�l.((Sepc�388DO Lab 'C) - - 0
(Policy No I D a mr- Cornpany if COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
LJ Cemfied copy is hereby furnished
❑ Certified copy Is filed with the county bul ins Inspection FOR APPLICANT TO FILL IN BUILDING ,
depenmend .// (PRINT OR TYPE ONLY) ADDRESS SA
Dale `f2-q Appscanl ^�S LOCALITY `
UA
r NO TYPE OF APPLIANCE OR EOPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORMERS NEAREST -
COMPENSATION INSURANCE CROSS ST
(This section need not be completed N the work involved by the ABSORPTION UNIT,BN MMAAPEBOK PAGE ' PARCEL
permit is far one hundred dopers($100)far less) AIR HANDLING UNIT CFM c ,.r p pna�q�e er
1 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 Bit p '
became subject to the Workers Compensation Laws
COMPRESSOR BTU i
r ,ua urn a SK"i"TU1E
Dale
Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT It after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL 2
provisions or this permit shall be deemed revoked FURNACE - FAU_ORAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter B ' HEATER SUSPENDEp UNR_ O 8
m
(comammmg with Section 7000)of Division 3 of the Burliness and WALL V AC
ICT.Cods and my license Is in full force and effect ACT.a
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License,Number (d'T57 5 1 LIC Clan
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p,
CanbactorsywgI U �J A, Data 3 -I 1 -Q� TOTAL S3_ FOIL
Ell I am exempt ander sec Plan check fee .. CNTAL
ICK 3
B&P C for firm reason PERMIT ISSUING FEES 7 O CHANGE nf}.
Date TOTAL FEE , QD LU
Signature
a.
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ON E—OW1 31121
- -
1 hereby affirm that I am exempt from 5255 the Contractor a License Lew NAME , J 1 AI 9:19
for the following reason(Section 7031 5 Business and Professions
Code) ADDRESS
❑ I as owner of the property or my employees with wages
as their sole compensation will do the work and the CRY TEL NO '
structure is not intended or offered for sale(Section 7044
Business and Professions Code) DIVINER
❑ I as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
lion 7044 Buratnese and Professions Code) t - '
CONSTRUCTION LENDING AGENCY CITY TEL NO a
I hereby affirm that there Is B construction lending agACTOR
ency for -
the performance of the work for which this permit 4s Issued ]�/ , _
(Sec 3097 Civ C) --,f '-1 7 r
DDREQ ( Av Av ' t✓4l 2,07 ,
Lentler'e Name -
CRY TEL No
Lender a AdamSTATt
I certify that I have read this application and state that the above I LICENSE NO 6 eg7r 3 CLASS
mforrnation Is correct I agree to comply with all County ordinance°
and Sate laws relating to building construction and hereby authorize
representatives of this County to enter upon the above+nentloned
property to nepemmn urpoeee - SEE REVERSE FOR EXPLANATORY LANGUAGE - - - - -
soNAruRE r oR AoeHr Olin