HomeMy Public PortalAbout6027 SULTANA AVE_Mechanical__ ✓ . cORY,�RS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
° fm that I have a certificate of consent to self
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insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No. Company
Certified 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 011
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C�i
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. ^ PROCESSED BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM L Y'
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject t0. ,the Workers'Compensation Laws. APPROVALS DATE INSPT 'S SIGNATURE`
Date pplicant COMPRESSOR,BTU ��i ROUGH _
NOTICE T6 APP I : If, bfter making this ertificate of VENTILATION SYSTEM FINAL `
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL•IDATI
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with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU—GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (f
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect. A.
A.
License Number J3 �� -Lic. Class C'22, I r U
Contractor)✓�67 5�m�,.e, mL O
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I am exempt under Sec.
Plan check fee �-
B.BP.C. for this reason'
PERMIT ISSUING FEE$
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , I
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
El 1, as owner of the property, or my employees with ADDRESS ACCT.$ tt
wages as their sole compensation,will do the work and CITY TEL. NO. 3 Q7 30.50
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER 1 WENS
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL TOTAL 30 m�`0 CHECK 30ec�...."
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there iso construction lending agency for. JH , CHANGE a�I�I ,�
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). D gm
ADDRESS 00010-013131
' i
2,2 V trN
Lender's Name �;
CITY D/ TEL. NO 0ip4 ( [l .,��
Lender's Address
STATELIC.
I certify that I have read this application and state that the 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
upon the bove-men ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ZA
Date
Signafur f A icon or or Agent