HomeMy Public PortalAbout5847 SULTANA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 816C(2-BO) LL=��/�l� ®p YI ®� L� ILII��
I hereby affirm that 1 have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING- IR CONDITIONING
a certifi�yi copy ttheerreo_LLSSec.3800,Lab.C.)
Poli Imo.y"�'� Company Z", eo-/9'71
Certified copy is hereby furnished. COUNTY OF LOS ANGELE BUILDING AND SAFETY
❑ Certified copy is filed It the cou ty I ild' g inspe tion BUILDING`:
e aJ en FOR APPLICANT TO FILL IN �/
Date �( a pli (PRINT OR TYPE ONLY) ADDRESS •
LOCALITY �•
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
CROSS ST
. j a d
(This section need not be completed if the work involved i ABSORPTION UNIT, BTU �V
by the permit is for one hundred dollars ($100) or less.) ( DISTRICT NOPROC v
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM i,�"` -
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU 15iFC-)
APPROVALS DATE INSPECTOR'S SIGNATURE IL
Date Applicant C/ COMPRESSOR,BTU ROUGH IL
NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM 9.
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION FURNACE: FAU V T &
FLOOR• BTU
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. /
LiceT�Lic.Class e-2-40
.,Q
Co ate
F1I am exempt rom the licensing requirements as I am a I C
licensed architect or a registered professional engineer ;Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
,
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi- ±
ness and Professions Code): ADDRESS
F1 1, as owner of the property, will do the work and the '
structure is not intended or offered for sale (Section I CITY TEL.NO.
7044, Business and Professions Code). OWNER Ll 0 7. 1. P
0 I, as owner of the property, am exclusively contracting ` ` o e o o 4 1
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 2 0 0 27 00
CONSTRUCTION LENDING AGENCY 1 CIT TEL.NO. -��
I hereby affirm that there is a construction lending agency o o v -
for the performance of the work for which this permit is CONTRACTOR �y�— ��
issued(Sec.3097,Civ.C.). 2 1 �]-A 1
Lender's Name ADDRESS7�J 40Xf,7 �O�`�►JO
Lender's Address CITY TEL.NOW6�7�,
I certify that I have read this application and state that the STAT L LIC.
above information is correct.I agree to comply with all County _LICENSE N G+� CLASS
ordinances and State laws regulating Heating, Ventilating and
'oning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to nter upon the above-mentioned property for
inSpec ' r
Si a of Per ee Date