Loading...
HomeMy Public PortalAbout6227 SULTANA AVE_Mechanical__ 76 WORKERS'COMPENSATION DECLARATION CE 818(2-80) A P P C A T U ON FOR P E RMu I�hereby%f(�jn tj at I ha#e a certificate of consent to self insure, or a cerxificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR NTIL.ATING-AIR CONDITIO,`I ING a efeif�id. co the e f Se .3800, ab. Po IQa Y L c party Certified copy is hereby furnished. COUNTY OF LOS A�IG.ELES BUILDING AND SAFETY Certified copy is filed with t county bu' ing in ection BUILDING ��77 depa) e��t�p�n .7 FOR APPLICANT TO FILL Ifil ADDRESS �/p� Date_ !, Applican (PRINT OR TYPE ONLY) f• CERTIFICATE OF EX PTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY COMPENSATION INSURANCE 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 dollars ($100) Or less.) DISTRICT NO. PROCESSED BY V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFMcc permit is issued, I shall not employ any person in any manner O so as to become subject to the Workers'Compensation Laws. BOILER BTU ri OO y 1, APPROVALS DATE INSPECTOR'S SIGNAT RE Date Applicant COMPRESSOR.,BTU yV1 CL W ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION FLOOR- FAUoe A BTU Y I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code,and my license is in full force and ��/ers ©l�I e effect. 3a 9?g c C_a n License Num er J Lic.Class QV- �y 7� �+ �'J �l Contract . AV" ate. �� / F1 i am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- ;23921 A iness and Professions Code). PERMIT ISSUING FEE$ a 0 0 0 0 0 8 Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I ° ° 4 a O O I hereby affirm that I am exempt from- the Contractor's NAME o 0 0 4Q Q License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS El I, as owner of the property, will do the work and the 1,24-;--86 CITY TEL. NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER O q , I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL / (Section 7044,Business and Professions Code). ADDRESS + CONSTRUCTION LENDING AGENCY CITY j5X, TEL.NO. 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is. CONTRACTOR r issuedSSec.3097,Civ.C.). Lenders Name ADDRESS D ed Lender's Address CITY TEL.NOg/ 331--(9ffi I certify that I have read this application and state that the STATEr► LIC. /+' �O t� above information is correct.1 agree to comply with all County LICENSE NO. �7 / Ka!z CLASS V ordinances and State laws regulating Heating,Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter on the above-mentioned roperly for ctio purp vzz:�= Z — 1gnature of Per ttee Date