HomeMy Public PortalAbout5830 SULTANA AVE_Mechanical__ ,WORKER$'COMPENSATION DECLARATION' APPLICATION FOR PERMIT
' I h��by+Offrtrti tAaj I have a certificate of consent to self •
•insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copf thereof(Sec. 3800, Lab. C.) 76-64 (REV. 10/81')
Policy Nd-r4 "pany�y-nd,iiai—iiiCZelCl
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
t.
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 5830 Sultana Ave.
• Date 2125185 Applicant JO Leafier_ LOCALITY Tem le Cit
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
i COMPENSATION INSURANCE CROSS ST. HerMoSa
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED DY
the permit is for one hundred dollars(;100)or less.) V /)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM (J
' permit isissued, I shall not employ any person in any manner
BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPEE R'S SIGN TORE
Date 'Applicant COMPRESSOR,BTU .36M 1C 00 ROUGH ✓ ,
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 rA
with comply with such provisions or this permit shall be
i deemed revoked. , i. FURNACE: FAUX GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU Jai
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 effect. 2A
License,Number 3 8 667 8 _Pc. Class C20. ► ii
o o o a o 8 -D
Contractor I a o 3 a 5 0 .
I am exempt under Sec.
Plan check fee 0 a 0 3 Q 5 0 cm)
�►
BAP.C. for this reason'
I —, Date: PERMIT ISSUING FEE$ 1 x
+ T-TOTAL FEE 0 2 2 8 8 5
Signature
OWNER-BUILDER DECLARATION PLAN 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):
❑ I, as owner of the property, or my employees with ADDRESS
i wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
�
E:] 1,
as owner of the property,-am exclusively contracting OWNER
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY Tem le
'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 RACTOI
(Sec. 3097, Civ. C.).
'ADDRESS
Lender's Name 26-3:1 T-nta
Aun-
- CITY TEL. NO.
Lender's Address '
—
STATE LIC.
I certify that I have read this application and state that the LICENSE NO, 386678 CLASS C2Q
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby auth Me representatives of this County to enter
upon the above ntion property for in ection urposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE '
Sign t e of Applicant or Age D e