HomeMy Public PortalAbout5076 SULTANA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9189 11
76A36,IC APPLICATION FOR PERMIT _,.:
hereby affirm that have a certificate n consent , self insure, VI^ 4,
or a certificate of Worker's Compensation Insurance, or a certified � ����'
E GREEN
copy thereof(Sec. 3800 Lab.C.)
HEATING - VENTILATING -AIR CONDITIONING
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified Copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
_. department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance at the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
1, become subject to the Workers' Compensation Laws.
Date Applicant
COMPRESSOR,BTU
{Ilr APPROVALS DATEINSPECTOR'S SIGNAIDflE
VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER. SUSPENDED UYIT_
(commencing with Section 7000) of Division 3 of the Business and f WALL
Professions Code,and my license is in full force and effect. _.
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License Number Lic.Class
aCC7.: a
Contractor - / Data t'- ' �,- V
❑ I am exempt under Sec. Plan Check fee Z 1TFW LU
B.&P.C.for this reason PERMIT ISSUING FEE$ r0TAE-
Date: TOTAL FEE41
Signature4r>i'�Yr]s�. <
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT \.rY'IIYr
1 hereby affirm that I am exempt from the Contractor's License Law NAME (-
for the following reason (Section 7031.5, Business and Professions 4n1L4"[�IV 'i �- W
Code, ADDRESS 4nlll [r+IV
❑ 1, as owner of the property, or my employees with wages
as their sole Compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL --
with licensed contractors to construct the project (Sac- ADDRESS
lion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITU TEL.NO.
1 hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit IS Issued CONTRACTOR
�f
(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 above LICENSE NO. CLASS
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 the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i 1
' SIGNATURE OF APPLICANT OR AGENT DATE