HomeMy Public PortalAbout6164 SULTANA AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 76A348DPW9/89 APPLICATION FOR PERMIT LIME GREEN.
78A364C
I hereby affirm that I have a certificate of consent to salt insure,
or a certifi rate of Wo'rker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) �-
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy Is hereby furnished.
DING
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ;*RESxV1r�
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, 1 shall not employ any person in any manner so as to BOILER.BTU O
become subject to the Workers'Com en tion Laws. / � 0
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
OTICE TO APPLICANT: If, after making this Certi Cate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU V VAI ON
LICENSED CONTRACTORS DECLARATION FLOOR BT
I hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER:. WALL
Professions Code,and my license is in full force and effect. I
License Number Lic.Class d� 8 _
.5 Q
Contractor Date 3303 13 ix-x..43 (C,
F1I am exempt under Sec. Plan Check fee _t L. Q
BAP.C.for this reason PERMIT ISSUING FEE$ 40TOTAL 122� 25 1-
Date:
TOTAL FEE CHECK K 1yi.^R �
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT iCHANGE ._)_;
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS 1;1,1'11,-1,1,1,1 0/ 9/9-4
1, as owner of the property, or my employees with wages 3;a P3.ec
as their sole compensation, will do the work and the CITY TEL.NO. Cr t'1 I�,.�[."
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). NER❑ ` t o
I, as owner of the property, am exclusively contracting MAIL ^
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
0 .�
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above I LICENSE NO. CLASS
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 above-mentioned
I
pe for ins p ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S
WUNATURE OF APPLICANT ORIAGENT DATE