HomeMy Public PortalAbout5955 SULTANA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA386 8C (2-80) LL Q���Q®� ®� LS. Ubu 0�
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-Alla CONDITIONING
a certifAAiedc thereof(S c.3800,L r�
Polic,YVo� °�C�pany � !
Certified co py is hereby furnished. COUNTY OF LOS ANGELES f BUILDING ARID SAFETY
Certified copy is riled with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. Y-0-n.
s' O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PROCESSEGFBY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner 3—'o P, O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU 13
APPROVALS DATE INSPECTO 'S SIG ATURE
Date Applicant COMPRESSOR,BTUy
ROUGH G
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL P 1
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ej'" VALIDATION
with comply with such provisions or this permit shall be S`(��
deemed revoked. FURNACE: FAU I GRAVITY 77
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter. HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. jLI..
/License Number Class p
Contractor Date 1�
INE] licensed
am exempt from the licensing requirements as I am a - ��
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ Q 5',7
Lic.or Reg.No. Date TOTAL FEE F 3 2 Urn
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a 0 0 0 0
1 hereby affirm that I am exempt from-the Contractor's NAME 2 0 - 4275
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS 0 0 „ ;I 1 r,x
1, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section •'J q, 1 61—,8 3
7044, Business and Professions Code). . � k
OOWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professioes Code). ADDRESS
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 CONTRACTOR issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO. 6
1 certify that I have read this application and state that the STAT
TENSLIC. rr77
above information is correct.I agree to comply with all County LIC
EE NO. CLASS "'4
ordin nces and at laws regulating Heating, Ventilating and
Air nditio ' g a d hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
C nt to nt upon ,th/e�a_bo��_e-mentioned property for
ii 'pe tion pup
i
Sig t of P mittee Date