HomeMy Public PortalAbout6358 SULTANA AVE_Mechanical__ ,pW.ORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
� 4reson
by�iffi'm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C. 76A364C CE-818(REV. 10/81)
Policy No. 1 o w Company C011( 4-ce" &J
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county b&AMQ%—)
' spec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS ct
Date Applicant LOCAU
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be coinpleted if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. �.--� / PROCESSED BY
the permit is foi one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
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 become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPE OR' SIGNATURE
Date Applicant COMPRESSOR,BTU 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 VALIDA I N
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 9 HEATER: SUSPENDED—UNIT-
'(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code
,,and my license is in full force and effect. !1 12.
be= GTQ
License Number IL100 J 1 Li
c.Lc.. Class TO L)' / L %P(J o ;) ,
Contractor[tl��-gn A'I70'1r(0�►�7,tg (' (f 0
❑ I am exempt under Sec. U si
Plan check fee _ 06
B.BP.C. for this reason' ACC l as
Date:
PERMIT ISSUING FEES 33073307 30.511 —
Signature TOTAL FEE (J.
1 ITEMS
OWNER-BUILDER DECLARATION iPLAN CHECK APPLICANT _
I hereby affirm that I am exempt from the Contractor's License , TOTAL�I AL 30®5113Law for the following season (Section 7031.5, Business and NAME
Professions Code): CHECK 30.50
El 1, as owner of the property, or my employees'with ADDRESS ,1 L:HF1h13E ,00
wages as their sole compensation,will.do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
( .. t il�t(71�—'3�l�� �/'��•;'
❑ I, as owner of the property, am exclusively contracting _
with licensed contractors to construct the project (Sec- S IL 0710 1 f}I i ll.'1•_+
tion 7044, Business and Professions Code). ADDRESS r ,
CONSTRUCTION LENDING AGENCY CITYTEL. NO.ZS
I hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). .
ADDRESS,5
Lender's Name '
CITY l�q TEL. NO
CITY
Lender's Address -A
I certifythat I have read this application and state that the LICE �q 7 '. LIC.
pp LICENSE NO. V� 7 CLASS
above information is correct. I agree to comply with all County
ordinances and State lawAplating to building construction,
hereby a t Iz a entatives of this County to enter
upo the a ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date I