HomeMy Public PortalAbout6210 SULTANA AVE_Mechanical__ x i aWORKER'SCOMPENSATION DECLARATION 76M840DPW 9/69 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm*that I have a certificate of consent to self insure, f(
or a certilreate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING "lul
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.
BUILDING r7
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS �L-
department. (PRINT OR TYPE ONLY)
LOCALITY 7:e Z
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. kt , y. ?)
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM DISTRICr NO. PROCESSED BY
I certify that In the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER.BTU .�
become subject to the Workers'Compensation Laws. _ �/ d '
1 � COMPRESSOR,BTU 6: DO� .06' APPROVALS DATE INSPECTOR'S SIGNAT E
Date le jApplicarit,-2�'/c�G_ i�� VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUG �(ITy
LICENSED CONTRACTORS DECLARATION FLOOR BTu• -� o� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number•�• � Lic.Class �z
Contract %l�L•y Dated-30-192 C
❑ I am exempt under Sec. Plan check fee O(,
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE a
'Signature Cr
OWNER-BUILDER DECLARATION ? EGK=APPCI6ANT -
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
ElI, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. �i,`7J��'� l?
structure is not intended or offered for sale(Section 7044, �� �' a -
Business and Professions Code). OWN
❑ R I, as owner of the property, am exclusively contracting
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with licensed contractors to construct the project (Sec- ADDRESS ��� �/ , :-7 ,--
tion 7044, Business and Professions Code). L-_v CHECK �r ..Jlu
CITY �� TEL.NO. 5_j btP _
CONSTRUCTION LENDING AGENCY / �' >V.
I hereby affirm that there Is a construction lending,agency for le
-1>�I'v��t
the performance of the work for which this permit s issued CONTRACTO G
(Sec.3097,Civ.C.). J } i
ADDRESS '#r i v!9 1
Lender's Name
I TEL.NO. L �f c r t'
�E! ����G v:Iti�• i AM i:4
Lender's Address STATE LIC. C ZV
1 certify that I have read this application and state that the above LICENSE NO,..Z 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
proper iinspe/��� oe
� �/ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT D E