HomeMy Public PortalAbout6272 SULTANA AVE_Mechanical__ ION
affirm
thER'SCOMPENSATate of consent to 20-0364CPW9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, �7
or a certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING `IILIII
copy thereof(Sec.3800 Lab.C.)
Policy No. 7_ y - ompany. , COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS Z
department. (PRINT OR TYPE ONLY)
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Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY V - L '+'
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
W�
(This section need not be completed if the work Involved by the MAP BOOK PAGE, PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH *nA1/QN
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL Aprovisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VA
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
—
(commencing(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number 44k.J$-L7 Ir Lic.Class—
L
Contractor���s ��'�nla — l
Plan check fee
ElI am exempt under Sec.
L
B.fl+P.C.for this reason PERMIT ISSUING FEE$ �3 a
Date: TOTAL FEE p L
L
Signature PLAN CHECK APPLICANT c
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Coe): ADDRESS
El I, as owner of the property, or my employees with wages i-A"_. °v
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, -
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting r` .,7 -D
with licensed contractors to construct the project (Sec- ADDRESS t•:•rT_ -_L
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I CONTRACTOR
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name _I_I Tr L,=r':
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE