HomeMy Public PortalAbout6361 SULTANA AVE_Mechanical__ WOthat I COMPENSATION
ate of consent to 7aA36aDPW9Is9 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate o}consent to self insure,
or a'ceZtificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
v�cy l ° y"ate
o.• Company �(/�19�J ' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING G'rj/� u r�
Certified coRpy is filed with th aunt building ins do FOR APPLICANT TO FILL IN ADDRESS V C�
de rt I. �. (PRINT OR TYPE ONLY)
80 LOCALITY Lr� a
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FR WORKERS' CROSS ST.
COMPENSATION INSUR NCE ABSORPTION UNIT,BTU
This section need not be completed if the work Involved b ASSESSOR
( P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit c_�
Is issued, I shall not employ any person in any manner so as to BOILER,BTU �/ y
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 0=2> 00 APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH /
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER / 2p*7
provisions of the Labor Code,you must forthwith comply with such FINAL Kg-.21Y-
J/yj��—�
provisions or this permit shall be deemed revoked. FURNACE: FAU ITCi J �y
LICENSED CONTRACTORS DECLARATION I FLOOR BTU O 4-0 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numbe �vv Lic.Class
6, u) Ate' 1ZlZ � ® c
Contractor Dtea
❑ 1 am exempt under Sec. Plan Check fee C
B.&P.C.for this reason PERMIT ISSUING FEE$ 3 F
C
Date: TOTAL FEE93
6��
Signature PLAN CHECK APPLICANT (J
OWNER-BUILDER DECLARATION s
1 hereby affirm that 1 am exempt from the Contractor's License Law NAME ® S-'
for the following reason(Section 7031.5, Business and Professions a
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages 3307 53■-Ij= t
tiLU -
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, 1 ITEM
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL TOTAL. 565 o 00
with licensed contractors to construct the project (Sec- ADDRESS 8 L �.� a 'v 1 t.){�j,.: 1=I°IyIJ
tion 7044, Business and Professions Code). e,� �,,�
CONSTRUCTION LENDING AGENCY
CITY O..J/G egg,l TEL.NO. �40 C HAltIE ■[I,I
I ,affirm that there is a construction lending agency for CONTRACTOR le
p
the erformance of the work for which this permit Is issued o
(Sec.3097,Civ.C.).
ADDRESS(� 'i ! i q
T 664-11115 1O IE- 1 3IJI3�.i—IJI.)01 1 12� i 913
Lender's Name • y 1k q �q I ,;�7
CITY!25
�` 1TEL.NO. Z �/ti s 1 Fi!f 11°Lender's Address �_ZI certify that I have read this application and state that the above LICEN (gs LIC.
V
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
r taUves of this County to enter upon the above-mentioned
p�ert �lnglftt�lon s 7- SEE REVERSE FOR EXPLANATORY LANGUAGE '
v U
SIGNATU F APPLICANT Oil AGENT-