HomeMy Public PortalAbout6229 SULTANA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA g g(2-80) !^ f>—Pl— ����B®p �1 ®9�C ��
I hereby Affirm that G hay(: a' certificate of consent to self
inture,dr a,certificste of�-rorkers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
•'a•c ti ied o*[hereof Sec.3800,L
�����_ O�9PJy � COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished.
Certi ied co y is filed with the county b270PZ,,�-
.tion FOR APPLICANT TO FILL IN BUILDING
depr/�,,�/p/�j,� /Date-��,�- -1�""'�pplicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C
COMPENSATION INSURANCE CROSS ST. d
(TNEAREST
his section need not be completed if the work involved ABSORPTION UNIT,BTU
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM IL
permit:is issued, I shall not employ any person in any manner O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU f-
r
APPROVALS DATE OINSPEC�TOATUR WDate Applicant COMPRESSOR,BTU NROUGHNOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINALExemption, you should become subject to the Workers'Compensation provisions of.the Labor Code, you must forth- � E.VAPORATIVE COOLER VALIDA I
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GR VITY
LICENSED CONTRACTORS DECLARATION ( FLOOR: BTU4196951,-
1 hereby affirm that I am licensed under provisions of.Chapters HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code,and my license is in full force and) D ��/ O
effect. n
License.N ber� *�. Lic.Class—
20 7;
Cont ate.
fLJ I am exempt from the licensing requirements as. I am a
licensed architect or a registered professional engineer Plan check fee 25%of above. A-392 2 A
! acting in my professional capacity (Section. 705.1, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ # o a 0 0 0 8
\.L•ic.or Reg;No. Date TOTAL FEE e 0.0 8 O O
HOME OWNER-BUILDER DECLARATION
� PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from-the Contractor's . NAME e o o [�. p
License Law for the following reason (Section 7031.5, Busi- 0 1.2 4 8 6'
ness and Professions Code): ADDRESS
1, as owner of theproperty., will do the work and the CITY TEL.NO:
structure is not. intended. or offered for sale (Section
7044''Business and Professions Code:).
OWNER
Ii
I; as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL _ g!
(Section 7044,Business and Professions Code). I ADDRESS (�(
CONSTRUCTION LENDING AGENCY I CITY TE.L.NO
I.hereby affirm. that there is a construction.)ending agency CONTRA O
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender s.Name ADDRESS 0 r�
Lender's Address I CITYTEL.N 33
I. certify that I"have read this application and state that the STAT ELIC.
above.information.is correct,l;agree td`comply with all County LICENSE NO.. sl Cl CLASS
ordinances and State laws regulating Heating,Ventilating and
Air Conditioning,and hereby authorise representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter K
the above-mentioned property for
iiia c ion p poses.
S' ature of Perm to Date _