HomeMy Public PortalAbout6345 SULTANA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION �������TI®� FOR PERMIT
I herebyraffirm that I have a certificate of consent to self
insure, or a certificate rf Workers' Compepsatio„n I,psurante, 76A364C 0-00HEATING - VENTILATING - AIR CONDITIONING
p f certified copy thereof (Sec. 3800, Lab. C.) 20-00
246 DPW 9/88
Policy No. Company
9
COUNTY OF LOS ANGELES BUILDING AND SAFETY
F-1 Certified copy is hereby furnished.
ElCertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING J ,tet,
y tion department. (PRINT OR TYPE ONLY) ADDRESS �� ,S S.11 73�!A r=
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 1-02FX01,JWe,
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. c T.
r (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROOES D B
the permit is for one hundred dollars ($100) or less.)
I I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
✓ , permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU AP OVALS DATE INSPECTOR'S SIGNATURE
9
g�. COMPRESSOR, BTU ROUGH
ZOO O Applicant
J NOTICE TO APPLICANT: If, afte aking this Certificate of I VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- i EVAPORATIVE COOLER VALIDAT401i
' with comply with such provisions or this permit shall be deem-
t ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: S
(commencing with Section 7000)of Division 3 of the Business WALL.'
and Professions Code,and my license is in full force and effect.
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License Number Lic. ClassI ® 0
u
Contractor Date tI
❑ O
I am exempt under Seca U
Plan check fee w
B.&P.C. for this reason. PERMIT ISSUING FEE $
i H
Date: Z
Signature I TOTAL FEE o
OWNER-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 &A)DOgggroy 0• apacoo
Professions Code):
// -elj(/[7td AY�Ue� 8
F-11, ltJI, as owner of the property, or my employees with �
wages as their sole compensation,will do the work and r.®�� ^� t ACC i°s
the structure is not intended or offered for sale Section CITY r�/i/w TEL. NO.
7044, Business and Professions Code).
OWNER A/®�� ���a� 7 `' °f3i
❑ /fff C!'s//
I, as owner of the property, am exclusively contracting I NEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS )4 9W 6 -DOTAL 37. 00
CONSTRUCTION LENDING AGENCY Ci � ���
7Y TEL. NO. 8 37.00
I hereby affirm that there is a construction lending agency for '8 y �
the performance of the work for which this permit is issued CONTRACTOR CHANGE °i]I?,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name CITY TEL. NO. I 0090-10100Z . //1
7/20/911
Lender's Address
I certify that I have read this application and state that the STATE LICENSE NO. C LIASS 1942 1 AM 7°19r
above 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
on the above-mentioned property for inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Applicant7or Agent Date (� @