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Home My Public Portal About6323 SULTANA AVE_Mechanical__ • WORKERS'COMPENSATION DECLARATION ! 76A364C fid �,fi R fir' ®fill ®rdi IIS lid r�I\Ll �� 1 hereby affirm that I have a' certificate of consent to self CE-818(2-80) Ir `>as A II II CI R Ir E u`�IIGII insure,or a certificatyy of Workers'Compensation Insurance,or I HEATING-VENTILATING-AIR CONDITIONING Ld reAflSec.3g00, C. vOOCC77 Company. is hereby furnished. COUNTY OF LOS ANGELES �� BUILDING AND SAFETY is filed with a county i nsp c 0 FOR APPLICANT TO FILL IN BUILDIN �7 ApplicantFF (PRINT OR TYPE ONLY) ADDRES LOCALITY 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,BTU CROSS T. 0 by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. dv PROCES O BY U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM (/ O � permit is issued, I shall not employ any person in any manner O so as to become subject to the WorkerensationLaws. BOILER,BTU �¢ U APPROVALS DATE INSPECTOR'S SIGNATURE Dat Applicant ��qf� COMPRESSOR,BTU CL ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM �� FINAL 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. FURNACE: FAU GRAVITY ) LICENSED CONTRACTORS'DECLARATION FLOOR: BTU 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 Prof s' nsCo , and my license is in full force and effect. License Numbe iC.Clas Contracrt r Date El 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). Lic,or Reg.No. Date TOTAL FEE 27 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 I, as owner of the. property, will do the work and the CITY ` TEL.NO. structure is not intended or offered for sale (Section I 7044,Business and Professions Code). OWNER z 0 0 a 5 A FJ I, as owner of the property, am exclusively contracting # 0,0 0 0 (I 1 with licensed contractors to construct the project MAIL I (Section 7044,Business and Professions Code). ADDRESS 2 0 0 .27.00 CONSTRUCTION LENDING AGENCY CITY L.NO. I1 hereby affirm that there is a construction lending agency 0 0 0 2 7.0 0 C5 f r the performance of the work for which this permit is CONTRACTO issued FSec.3097,Civ.C.). 0 625-81 Lender s Name ADDRESS Lender's Address CIT lk TEL.NO. I certify that I have read this application and state that Lite STATE LIC.' above information is correct.I.agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating-Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE my to ter upon�Ihea�o�veetnioned property forspe 'on urpot nature of Permitte ION WORKER'S I have a certificate of consent to 76M66DPW9189 APPLICATION FOR PERMIT LIME GREEN 76A364C ,! hereby affirm that I have a certificate of consent to self insure, Or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ElCertified copy Is filed with the county g p buildin ins ection FOR APPLICANT TO FILL IN BUILDING �^ department.• (PRINT OR TYPE ONLY) ADDRESS jLV�. Ir�-- Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. e-j COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed If the work Involved by the ASSESSOR MAP BOOK Z PAGE 01_1 PARCEL d!:%2-J0 permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. d O COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL L, provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license Is In full force and effect. License Number Lic.Class jjr ,,,,J� Dki C,,e G Contractor Date - C ❑ Plan check fee - C I am exempt under Sec. E_iL.iC :•;•q )Y 7 B.&P.C.for this reason PERMIT ISSUING FEE$ iti a 5E Date: TOTAL FEE g i : 4 Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �'i j r:; '-h3 ».,1,� �,._ �� Q =ave I hereby affirm that I am exempt from the Contractor's License Law NAME •'yW J�41T + ; e; for the following reason(Section 7031.5, Business and Professions ti r—=• _: •J o . Co e): ADDRESS �^j Z 3 I, as owner of the property, or my employees with wages y as their sole compensation, will do the work and the CITY ti�,.4,A (�G� 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 MAIL 5121 All 9:21 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lenpding agency for CONTRACTOR the erformance of the work for which this perm Is issued i (Sec.3097,Civ.C.). ADDRESS Lender's Name 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 representativsof this County to enter upon the above-mentioned p party for spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - SIGNPPLACANT OR AGENT ATURE n DATE