HomeMy Public PortalAbout6242 SULTANA AVE_Mechanical__ � �. µ WORKERS'COMPENSATION DECLARATION to self APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent
�, insure;or+a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CEA3818(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 •� �W
(PRINT OR TYPE ONLY)
tion department. ADDRESS ��Z �` LL�Ip` �-„r
Date • Applicant LOCALITY 1 ��
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CJ
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. ( PROCESSED BY
(This section need not be completed if the work involved by �-,
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM `
I certify that in the performance of the work for which this ✓r /
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'CO n5atian LOWS. ) APPROVALS DATE INSP� ¢R' SIGNAT E
Date �' Applicant '` ai;kr COMPRESSOR,BTU • 1 /� ROUGH
'NOTICE TO APPLICANT: If, after making thi erti o to of, VENTILATION SYSTEM FINAL
Exemption, you should become subject t the rkers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA-IDAT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUAV
GRITY _ " 1 d
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. 9L
4 O
License Number Lic. Class ® tJ
Contractor Date
b
❑ I am exempt under Sec.
Plan check fee 9L
B.&P.C. for this reason PERMIT ISSUING FEE$
Date:
TOTAL FEE
Signature
DOWNER-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 ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professi6ns Code).
OWNER A)& CW9_::'A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL `u`Iii d1 °�{``
tion 7044, Business and Professions Code). ADDRESS jp� _ C _
CONSTRUCTION LENDING AGENCY p S't I E1�t
CITY L2 �� TEL. NO. 7 i.
I hereby affirm that there is a construction lending agency for9ydT TOTAL AL. 4—"-- o 010
the performance of the work for which this permit is issued CONTRACTOR ® L�rs'442.00
(Sec. 3097, Civ. C.). =' E I:
ADDRESS ;�f NGIE M1)_)
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC. IjCl_I3--0. i 1/
1 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 "S j1 AM 9:j{_
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the ob -mentioned property for ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7
Si ature of App t o gent
' n
Date