HomeMy Public PortalAbout5074 SULTANA AVE_Mechanical__ WORKtI have IPENSATION DECLARATION 7SA32GOG"DPW9189 APPLICATION FOR PERMIT LIME GREEN
I hA,ably a(hrm that) have a certificate of consent to self Insure 7a�L3BaC
or a certificate of Worker s Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lab C) LI
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ CertBied copy is hereby furnished
❑ Carolled copy in filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
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department (PRINT OR TYPE ONLY) S L..L A
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Dale , Applicant NO TYPE OF APPLIANCE OR EOUIPMEM FEE Lc
(., CERTIFICATE OF EXEMPTION FROM WORKERS CROSS NEAREST
IO
COMPENSATN INSURANCE
(This section need not be completed It the work Involved by the MMAAPEBOOK PAGE PARCEL
permit Is for one hundred dollers(8100)or leu) AIR HANDLING UNIT CFM a�e�rp pCLEfl4Ea sly r
I certify that in the performance of the work for which this permit o
is issued I shell not employ any person In any manner so as to BOILER Bit �ap
become subject to the Workers Compensgllon Lowe
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V Dale App) VENTILATION SYSTEM
NOTICE TO APPLICANT
it
or
me king this Ce rtl Certificate of ROUGH
Exemption you should becom lair to the Workers (ompemetion EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such i FINAL
provisions or this permit shell be deemed ranked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION
I hereby affirm that I em licensed under provisions of Chapter 9 HEATER SUSPENDED U R_ /
(commencing with Section 7000)o1 Division 3 of the Business and WALL (o O
Professions Code and my license Is In full twos and effect
i3 �32S1 $ C
License Numb�1er�/ Q Lld Clew ACCT.AT
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Contractor�C� �`t Data 3 —! 3303 [, 43.90 8
F-1I am exempt under Sec Plan check fee 1 ITr�pec h7
B dP C for this reason PERMIT ISSUING FEES 0 TOTAL 43 - 900
Date TOTAL FEE ya ��LLri����uu--��CHECK 43.r19r0 W
Signature 4rs9`a .010 co
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I em exempt from the Contractor a License Lew NAME ,
for the following reason (Section 7031 5 Business and Professions❑ utxtu�—LIW 1 1 AM 31 9.50/s 14/96
Code) ADDRESS I as owner of the property or my employees with wages 531E
as their sale compensation will do the work and the CITY TEL NO
structure is not Intended or offered for sale (Section 7044 _
Busmene and Professions Code) 4fNNER L G
❑ I as owner of the property em exclusively contracting MAIL
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with licensed contractors to construct the project (Sec MWWRESS 50 `f ,{ ^
tion 7D44 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CT' , e TEl NO, O
hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit 4a leeuetl NTRACTOR
(Sec 3087 Civ C) i y
AODPES9
Lender a Nemo TEl
Lenders Address STATE UC
I certify that I have read this application and state that the above LICENSE NO CLASS 6120
mfonnatton m correct I agree to comply with all County ordinances
and Stele laws relating to building construction,and hereby audWrize
representatives of this County to enter It the above mentioned
property for inspection u see SEE REVERSE FOR EXPLANATORY LANGUAGE
TUNE Of R �