HomeMy Public PortalAbout6121 SULTANA AVE_Mechanical__ fWORKERS'COMPENSATION DECLARATION to self APPLICATION FOR PERMIT
'Alnsu elTerej�-oraafiIrm that I have a certificate of cocertif cote of Workers'Compensat on ent Insurance,
or a certified copy there c. 3800, Lab. C.) 76A364C HEATING - VENTILATING - AIR CONDITIONING
a l CE-818(REV. 10/81)
Policy NoWP87051 Company Fremont.
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
tion department. ADDRESS
5-15-87 Kamor A.C. (PRINT OR TYPE ONLY) LOCALITY
Date Applicant Temple Cit CA
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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.) (�
Ux
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
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPE ORGNATURE
Date Applicant COMPRESSOR,BTU 16 M- 10 00 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU X GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 55 M 10 100
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: 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.
IL
License Number 165064 Lic. Class C-20 8 Outlets 14 00 u
C
A
Kamor, . . , O
Contractor Date 5-15-8 7
❑ I am exempt under Sec. U
Plan check fee
B.&P.C. for this reason t/l
Date: PERMIT ISSUING FEE$ 10 50
Signature TOTAL FEE 44150
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. #
7044, Business and Professions Code).
ElMrOWNER d Ado o4111,50
. KonraAndersen I, as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 6121 Sultana Ave.
CONSTRUCTION LENDING AGENCY CITY Temple City TEL. No. 286-6344 a a q"5
I hereby affirm that there is a construction lending agency for $
the performance of the work for which this permit is issued CONTRACTOR , 0 0
(Sec. 3097, Civ. C.). Kamor A.C.
Lender's Name ADDRESS 60 N. San Gabriel
CITY Pasadena TEL. NO.795-7524
Lender's Address STATE LIC.
I certify that I have read this application and state that the LICENSE NO. 165064 CLASS C-20
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
the above-m tinned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
uQ�r5-15-87
$igna ure of i ant or Agent Date