HomeMy Public PortalAbout5953 SULTANA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 878C(2-80) A P P L I C AT B O N FOR P E R S u
I hereby affirm that I have a• certificate of consent to self t�
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.�6$I00,Lapq�.� `�
Policy 140� ✓Y It mpahy ,�G2 COUNTY OF LOS ANGELES - BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN
Date Applicant •I (PRINT OR TYPE ONLY) ADDRESS
I LOCALITY /i CC
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
I CROSS ST. d
(This section need not be completed if the work involved I ABSORPTION UNIT, BTU
by the permit is for one hundred dollars ($100) or less.) I DISTRICT NO. PROCESSED V
I certify that in the performance of the work for which this iAIR HANDLING UNIT,CFM t/ " O
permit is issued, I shall not employ any person in any manner a ,.
so as to become subject to the Workers' Compensation Laws. ' BOILER,BTU U
f APPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicantCOMPRESSOR BTU / CL
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 77-FT.—A z
FINAL
Exemption, you should become subject to the Workers' `� f
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: B U
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ess and Professions Code,and my license is in full force and ! 2
effect. �/ ,.t f) !� V
License Number
/�L=L Lic.Class C fir/
Contractor b,L Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ m d
1
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 5 3.2 5.A
1 hereby affirm that I am exempt from- the Contractor's NAME 0 0 0 0 0
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
El I, as owner of the property, will do the work and the TEL.NO. ;o,o o 4 7,.'] 'E' czi
structure is not intended or offered for sale (Section CITY
7044,Business and Professions Code).
OWNER C n ) 0 9. 1 6783
r_1
DL
I, as owner of the property, am exclusively contracting �
with licensed contractors to construct the project !MAIL
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is I 6� gL16WG V-11- (L
issued(Sec.3097,Civ.C.). !
Lender's Name ADDRESSgee
Lender's Address I ITY OAK, TEL.NO. 77 cPl—�
I certify. that I have read this,application and state that theTATE LIC.
above information is correct.I agree to comply with all County LIG NSE NO. CLASS
ordinances and State laws regulating Heating,Ventilating and
Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
o ntY t e ter upon the above-mentioned prop ty for
u
ectiolikyoses.
Si1PftffMr6TPermittee Date fI