HomeMy Public PortalAbout5702-5704 SULTANA AVE_Mechanical__ ~F WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
At Y.I'geo6by*fIPrrrr`.that-l•Rave a certificate-of consent to self 4
*sure, qr a certii19cdte'hf;.*orkers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C ,
CE-818(REV. 10/81)
Policy.No:' Company
"C6rtified'copy is hereby.furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY'
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date -Applicant LOCALITY -
• NO. TYPE OF APPLIANCE OR EQUIPMENT r FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS sr.
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT N PiF0CE9SED BY
the permit is for one hundred dollars(;100)or less.)
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, BOILER, BTU
so as to become subject to the.Workers'Compensation LOWS. APPROVALS DATE INS�TOR'S SIGNATURE
Date�� h
sr? Applicant^ - `— COMPRESSOR, BTU �d ROUGH
00
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 VALIDAT
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY ® `�
LICENSED CONTRACTORS DECLARATION FLOOR' —BTU
-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force
//and
yyefffect. a/p /
License Number Lic. Class��! , (J [ ` U
]
Contractor v "— IM4— Date L 1t4O` 0
#' 9 u
❑ I am exempt under Sec. Q 7, J ;� �8 8 IN,
Plan check fee r r' IL
`B.BP.C. for this reason' fy a s
Date: PERMIT'ISSUING FEE$ CJ
'
Signature TOTAL FEE
`• OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
Thereby offirm•that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, asowner'of the property., or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the 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 (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
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.).
��''^^�� ��,� I
Lender's Name�E� �� y� ADDRESS' �'
_^ �I �1��� CITY TEL. NO.
Lender's Address �CX� O
I certifythat I have read this application and state that the STATE LIC.
pp 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
U13,911he above-ment' ned operty for ins ection purposes. ( SEE REVERSE FOR EXPLANATORY LANGUAGE
,OW --/f�
SI Lure of A plicant or Agent Date