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HomeMy Public PortalAbout6326 SULTANA AVE_Mechanical__ ^ .,WORKER!+'COMPENSATION DECLARATION ���C PW 9/89 APPLICATION FOR PERMIT LIME GREEN I hereby atfirm,.that'I have a certificate of consent to self insure, or a certifittata.of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy-thereof 7,S01.980 .C.) Policy No. CG pang COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. Certified c y is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGADDRESS �51 216 go/_-'A•�44 dopa me (PRINT OR TYPE ONLY) Date Appllcant d- VNW 7/?HC//W LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CE IFICATE OF EXEMPTION FROM WORKERS' CROSS ST. &JI -9 it-­f A-V— COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed if the work involved ASSESSOR ( b p Y the MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to BOILER.BTU become subject to the Workers'Compensation Laws. ��'VC 7 -00 �Q� .•-�� 2 COMPRESSOR,BT APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: G !� 101-0ALIDATION LICENSED CONTRACTORS DECLARATION FLOOR I hereby affirm that I am licensed under provisions of Chapter 9 HEATER, SUSPENDED I UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. r • License Number Z Lic.Class e 0 IAC M r_cFI��lC�1 �' ' poll. a Contracto Data C ElI am exempt under Sec. Plan Check fee a D BAP.C.for this reason PERMIT ISSUING FEE$ h Date: TOTAL FEE LL! Signature 0 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT c) 6 1 hereby affirm that I am exempt from the Contractor's License Law NAME 4g4j�-C S 5AI.S4^r71 Tjt+/CJ� , for the following reason (Section 7031.5, Business and Professions Code• /C+ TA ❑ ADDRESS ��S'�. f9A+'��� GAG A _Cr_ / }i 6AI I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY 402_._�API.4 9?(670 6 TEL.NO.S/J "'7fG-� .fit 'a■�!f� structure is not intended or offered for sale (Section 7044, — r: Business and Professions Code). OWNER / V I A f L A(j ❑ I, as owner of the property, am exclusively contracting MAIL n rryP— 1 /4v� I 0 i AL 93-00 with licensed contractors to construct the project (Sec- ADDRESS 6 � ?j`�p -5 V1_ rAe--1 A — "'HECK :�I�: tion 7044, Business and Professions Code). ■�j`;_i CONSTRUCTION LENDING AGENCY CRY 0,4r►C�-A g R I L TEL.NO. CHANGE I hereby affirm that there Is a construction lending agency for , ('HANDL � the performance of the work for which this permit Is issued CONTRACTOR �/f aCgAI nJ JC q t e © r (Sec.3097,Civ.C.). ! ADDRESS rL S~ IF. S,4N-rt CLIAP�R S'', s 6 1'•E— ISI 1 `pi s_!i'I Lender's Name /�,, G� CITY ALID�� /r P TEL.NO. Is,Vtr+.lt� 77f�� L7 1 fill N*2 Lender's A re s I certify at I ve read this application and state that the above LICENSE NO. s^� 4 Z LIC. C 2—C�;) inform on is orrect. I ag a to comply with all County ordinances and ate Is r ating i Ing construction,and hereby authorize rep r sent C enter upon the above-mentioned pr art or inspect' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 2I- SI URE OF APPLICANT OR AGENT DA