HomeMy Public PortalAbout6049 SULTANA AVE_Mechanical__ WORKERS'COMPENSATION bECLARATIO�I C.E-81 C fid f �j� d� �r ® POR I�E R���,
I hereby affirm that I have a' certificate of consent to self C.E-818 (2 80.) I�If— del Il POR fr
insure,,or.a certificate of Workers'Compensation Insurance,o'r. ,�qEAylN(y_y,Ey�TIL�►'lflN('y_AIIFd COQ®BTIOIMVIIT
Poartified copy thereof(Sec.3800,Lab.C.) 1
Policy No. Company
0 Certified copy is hereby furnished. •
COUNTY OF LOS ANGELES f BUILDING AND SAFETY
I. c
❑
Certified copy,ii filed with the county building inspection BUILDING
department. FOR APPLICANT TO'FILL IN °
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
,
yJ_ LOCALITY
CERTIFICATE OF EXEMPTION•FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT /FEE
COMPENSATIONINSURANCE ' NEAREST }
_ I CROSS ST. O
:(This section need,.not be completed if the work involved ABSORPTION UNIT,BTU ,
by the permit`is for one hundred dollar's ($100) .Or4pss.) [)ISTRICS NO, PROCESSE BY V'
I certify that in the performance of the work for which'this AIR HANDLING UNIT,CFM' �I
a�. 0
permit is issued, I shall not employ y person in any manner i•' O
sons ktob�ecomebject to the W rs' Compensation Laws, BOILER,BTU HAPPROVA
-LS DATE INSPECTOR'S SIGNATUREApplicant' , COMPRESSOR,BTU_ .25060' .
ROUGH I N
NOTICE TO APPLICANT: If, after making this Yertificate of'
VENTILATION SYSTEM - FINAL �-a`r - Z
Exemptjon, you should become subject to he. Workers' '
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER "
with comply with such provisions or this permit shall be. VALIDATION
deemed revoked.
FURNACE: FAU G IT .. ,.
LICENSED.CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of ChapterIHEATER: SUSPENDED UNIT _
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
s and Professions Code, and my license..is.in full force,and. '
effect.
License Number) tic.Class
Contractor Date / moi`/ �.
'• I am exempt 'f om the licensing " irL�NS t�up'le(am a I '
licensed architect or a registered professional engineer ;Plan Check fee 25%Of above.
acting in my professional capacity (Section-7051, Bus- ) "
iness and Professions Code): PERMIT ISSUING FEE$ (?
Lic.or Reg.No. Date TOTAL FEE V 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that•-I am exempt from-the Contractor's i .NAME � �5 4.3,2.A
License Law-for the following'reason (Section 7031.5, Busi- �I '�o'.o. o -o`o$
' ness and Professions Code): { ADDRESS I 1
I, as'owner of the property, will do the work and theII TEL.NO. i I 2 P c 30.50
I structure is not intended or offered for sale (Section CITY ,
7044,Business and Professions Code). '0'a o 3 0,5 0 0'
OWNER
0 I; as owner'•of-the property, am exclusively contracting O 9,2 0=8 3-
with licensed contractors to construct the project MAIL '
(Section 7044,Business and Professions Code). ADDRESS
,'CONSTRUCTION LENDING AGENCY CITY a EL.NO.
I hereby affirm that there (s a construction lending agency CONTRACTOR
for the performance of the work for which this permit is
issued SSec.3097,Civ.C.).
Lender s Name ADDRESS
Lender's Address
CITY TESL.NO.
I certify that I have read this application and state that the STATE LIC. 1
above information is correct.I agree to comply with all County LICENSE NO. CLASS " R
ordinances and .State laws regulating Heating,Ventilating and I
Air Con 'tinning,and hereby authorize representatives of this f SEE REVERSE FOR EXPLANATORY LANGUAGE
Count o enter upon the'above-mentioned gro.,erty for
�e►Is purposes. .;'
Sig ature of Permit a to 1
d,-