HomeMy Public PortalAbout6234 SULTANA AVE_Mechanical__ WORKERS' I ha e a certificate
DECLARATION •APPLICATI®N *FOR PERMIT
I hereby affirm that I have a certificate of consent to sel) i
11
insure, or a certificate of Workers'Compensation'Ynsurance; 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) I.
-818(REV. 10/81)
Policy No. Company
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
ADDRESS Z
tion department. (PRINT OR TYPE ONLY)
Date Applicant I LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ' �`
COMPENSATION INSURANCE CROSS ST. LCA
(This section need not be completed if the work involved by I ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less}) AIR HANDLING UNIT,OFM
I certify that in the performance of-the work for which this
permit is issued, I shall not employ any person in any mariner .'
so as to become subject to the Workers'CompensgTiL s IBOILER,BTU APPROVALS DATE/ INSPECTOR'S SIGNATURE
Date 3-I" Applicant '� \//►ICT COMPRESSOR,BTU ROUGH 1 1.-r
NOTICE TO APPLICANT: If, afte king this Certificate of VENTILATION SYSTEM FINAL G-/
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-' l EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. I FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR -'BTU
I hereby affirm that I am licensed under provisions of Chapter 9 ! M HEATER: . SUSPENDED UNIT `�
"(commencing with Section 7000)of Division 3 of the Business 1 WALL
and Professions Code,and my license is in full force and effect. IL
License Number Lic. Class
Contractor Date O
❑ V
I am exempt under Sec. I Plan check fee
B.BP.C. for this reason FA
I PERMIT ISSUING FEE$
Date:
Signature
TOTAL FEE '
� I
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business.and NAME
Professions Code):
I, as owner of the property, or my employees with i ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. I
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). ( c
OWNER L
.• ❑ 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. 37Q • a ,
1 hereby affirm that there is a construction lending agency for - {• a r (' —
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE 11C.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby auth r'ze representatives of this County to enter I,
thea ove ntioned roperty for inspectio, purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S' nature of Applicant or Agent Dote