HomeMy Public PortalAbout5636 SULTANA AVE_Mechanical__ DEC
WORKERS CI have,COMPENSATION cate ofA ns - APPLICATION FOR- PERMIT 4
I hereby affirm that I have.a certificate of consent to self,
insure or a certificate of Workers' Compensation Insurance HEATING -'VENTILATING - AIR CONDITIONING '
or b certified ccoppyy�thereof(Sec 3800,'�aobQCT) 70-00,1 C
Pohry NoLF x'ompanyJ�l�•y � _M DFv,'ve_e - • -
❑ COUNTY OF LOS ANGELES + tBUILDING AND SAFETY
Cernfied�copy is hereby furnished
t
Certified copy is filed with he county building rl nspec FOR APPLICANT TO FILL IN _ BUILDING
" ion department ,
(PRIM OR TYPE ONLY)
,Date t<<%`ICjO •Applicant 4 MrM LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT - r,FEE
` CERTIFICATE`OF`EXEMPTION FROM WORKERS ' NEAREST
COMPENSATION INSURANCE I CROSS ST t
' (This section need not be completed If the wark'Involved by ABSORPTION UNIT BTU NS4RICT NO PROCESSED BY - -
+ " the permit is for'one hundred dollars ($100) or lass ) r
4 AIR HANDLING UNIT CFM d/5 D
I certify that In the performance of the work for which this -
permit is issued, I shall not employ any personlin any manner . f `
so as to become,sublect to the Workers Compensation Laws Y' - - BOILER BT ` APPROVALS DATE NS ORS SIGNATURE
Date Applicant ` - �- COMPRESSOR BTU 6' 200
ROUGH
t+ - NOTICE TO APPLICANT If, after making this Certificate of VENTILATIONSYSTEM FINAL ' +
Exemption "you should become subject to the Workers `
` Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ' VALIDATION
f with comp)y with such provisions or this permit shall be deem - ,
L ed revoked r FURNACE FAU GRAYILY�� -
sa I LICENSED CONTRACTORS DECLARATION •� FLOOR BTU YY''LL��
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT— `
-(commencing with Section 7000) of Division 3 of,the Business JL WALL
Tend Professions Code and my I(cense ism full force and effect j
2 z2 ZSR d
License Number Uc Class Poo.
U
Contractor w Date � `` "\ - r be
❑TM I am exempt under Sec 6 G
• t • Plan check fee
` B 8P C for this reasonN
Date PERMIT ISSUING FEE $ 3 _ z
Signature TOTAL FEE '
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
Professions Code)
_ ACCT ,
I, as owner of the property or'my, ADDRESS
employees with 'T
,wages as their sole compensation, will do the work and . j j
ihe,structure Is not Intended or offered for sale (Section CITY ,. - TEL NO _ 31:07 tt (rr .�
7044,Business and Professions Code) OWNER, yy�Q.�-yy„2, k _ T I 1 ITEMS
E3I, as owner of the property am exclusively contracting' ^• - _`
with licensed contractors to construct the protect (Sac MAIL + TOTAL f J d0
tion 7044 Business and Professions Code) ADDRESS . V t t
CONSTRUCTION LENDING AGENCY CI�� TEL NO >� CHUK ``7'jJf2
I hereby affirm that therells a construction lending agency for TCHMISE - ,r(;I
the performance of the work for which this permit Is Issued CONTRACTOR ,
(Sec 3097 Cry C ) _ 1 •-i _ - ' `
ADDRESS `�o J S ._.. t« i s :I��Q�_IwL�1 , I�/ 4�'7f I
.Lender s Name �
A ITr Jv<y� TEL No I, 3130 1 ' Ahi:U:1-
Lander s Address ' t *7s�-
I certify that I have read this application and state that the LICENSE NO cu$ ZZ 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 '
u nth abov -manhoned property for ins echo purposes - '
�� A �l "SEE REVERSE FOR EXPLANATORY LANGUAGE- _ •
Signature of Ap hcant or Agent 'DDate U_