HomeMy Public PortalAbout6237 SULTANA AVE_Mechanical__ �AI�KE. S'COMPENSATION DECLARATION CE-8 B (2-80) d=�1 L� t�T II®u ®R UT
y 'a_} ErYff t�laA'I have $ certificate of consent to self '1 1
llisure'or'ft e&rfifiptetof Workers''Compensation Insurance,or HEATING-VENT ILATI FIG-Alp@ CONDITIONING U
a certifiedco �jthmpereof(Sec..38'00,Lab.C.)
Policy No. `884goany Zenith
,IQ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN ADDRESS 6237 N. S111 tana
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY TpMn
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTI1 CROSS ST. O
by the permit is for one hundred dollars (5100) or less.) DISTRI, V PROCESSED 8,Y V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Ir
permit is issued, I shall not employ any person in any manner 5-, O 0
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS ATE INS OR•SSIGN TUBE W
Date Applicant 1 COMPRESSOR,BTUROUGH �� / N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL z
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. 1 FURNACE: FAU X GRAVITY1 f Q
LICENSED CONTRACTORS DECLARATION FLOOR: BTU J�
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
effect.
License Number.221751 Lic.as.C 2 0
Contractor Date
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-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS r Q
I, as owner of the property, will do the work and the TEL.NO. ��fQ f`
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting Dan Vi-ray
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADORE
" 6237
CONSTRUCTION LENDING AGENCY CITY Tem le CityTEL.No.985-905 5 !o �O 5�
I hereby affirm that there is a construction lending agency CONTRALTO e�
for the performance of the work for which this permit is '
rVqn
issued(Sec.3 civ.C.). 13 50 E. Las Tunas Dr.
Lender's Namee ADDRESS
Lender's Address CITY TELGabrlel TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above' ormation is correct.I a ree to comply with all County LICENSE 1,x,2175.1 CLASS C20
ord' ane.s and State laws r u ting Heating, Ventilating and
Air Con itioning,and her y thorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Co to enter upon//t bove-mentioned prope y for
i p n purposes. R
Signature of Permittee V Date