HomeMy Public PortalAbout6371 SULTANA AVE_Mechanical__ (2) e WOR)`S2RS'COMPENSATION DECLARATION � CEA 818 C(2.80) �P P l� C AT�O N FOR P E rR UVp T
I {"rebN`afflrm that I have a• certificate of consent to self
insure, e, ac`certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certiPle�r copy here ec.3800,Lab.gC.)
r$�j " !� p y �i1'� ��N
Policy NOIA an -
❑ Certified ropy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with tf county building in ection BUILDING
Datedepartmen FOR APPLICANT TO FILL IN
pplicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATrOF EXE PT N NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
FROM WORKERS'
COMPENSAT INSURANCE NEAREST
CROSS ST.
(This section need not be completed if the work involved ABSORPTION UNIT, BTU a
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCE EDB V
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM O
permit is issued, I shall not employ any person in any manner (J O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPE OR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU ROUGH /' d
NOTICE TO APPLICANT: If, after making this Certificate of im N
VENTILATION SYSTEM FINAL z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G AV TY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED NIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and ,
effect. , t!
License Number_<U3 Lic.Class
Contracto !' j a e
ElI am exempt from the licensing requirem is as I a a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from- the Contractor's NAME aZy .� v -
License Law for the following reason (Section 7031.5, Busf-
-ness and Professions Code): ADDRESS �::•:: v�
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO.,,_Nqp
7044, Business and Professions Code).
❑ OWNER' -
I, as owner of the property, am exclusively contracting Jim panro
with licensed contractors to construct the project MAILy` 00
(Section 7044,Business and Professions Code). ADDRESS :�
Ay—
CONSTRUCTION LENDING AGENCY CITYTEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR CtZC 0
issued(Sec.3097,Civ.C.).
Lender s Name ADDRESSi ._
l_1 �-'27/29
Lender's Address CITY TEL.NO, o _ /�} f
A I �e Z
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE IN CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE' FOR EXPLANATORY LANGUAGE
County to enter upo the above-mentioned property for
n ection purposes.
i ature of Permittee Date