HomeMy Public PortalAbout6370 SULTANA AVE_Mechanical__ WORKER'S COMPENSATION
ate of consent to 76A348DPW9189 APPLICATION FOR PERMIT LIME GREEN.,
I hereby affirm that�I have a certificate of consent to si31f insure, 76A364C
or a certificate of Workers 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.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGss (951c) c5UL7A
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY TC .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by 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. / rJ
COMPRESSOR,BTU V�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of d 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: FAU G I
LICENSED CONTRACTORS DECLARATION / FLOOR BTU D VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED 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 Number Lic.Class
' ACCT.It a
Contractor Date i i°r 514.
'�' C
❑ I am exempt under Sec. Plan check fee `'`'� f ���� 't° C
B.&P.C.for this reason PERMIT ISSUING FEEC
Date: TOTAL FEE TOTAL 94 m 9. C
Signature PLAN CHECK APPLICANT C °CHECK 940515 u
OWNER-BUILDER DECLARATION CHANGE 011
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason(Section 7031.5, Business and Professions
Co 0 e): ADDRESS 1313110—I,pI]1 5/ 7/93
$3
1, as owner of the property, or my employees with wages a _ i 5
as their sole compensation, will do the work and the CITY TEL.NO. ?591 1 AM 9e,as
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER .J off ow LImA
❑ I, as owner of the property, am exclusively contracting MAIL .49246
�i t_6 D��� �
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). CITY SA� GAG '1EL_ TEL.NO (� 5J-(ps1toz
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(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 relatin o building construction,and hereby authorize
repres tives of thi County to enter upon the.above-mentioned
t f r inspectiq purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
, 3 31 q3
SI OF APPLI NT ��' DAT