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Home My Public Portal About6420 SULTANA AVE_Mechanical__ p.• �'i WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT 31 hereby h firm that I have a certificate of consent to self 'I.w,ire, or•a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING o rtified copy thereof(Sec. 3800, Lob. C.) 76A364C r�� I CE-818(REV. 10/81) i�llc o.��is Company LL�JI! j�(�� Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS ��ffii r'/ (PRINT OR TYPE ONLY) At. 6111IN111A Date I Applicant 0 LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C RTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY the permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM . 'f permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. I BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant ( COMPRESSOR,BTU coo ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA DATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY /+17—� LICENSED CONTRACTORS DECLARATION FLOOR BTU G ` I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED—UNIT—'(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full fo ce and effect. ,.r O "/ License Number Lic. C ss____IC�L�L ► L7 Contractor• l to O ❑ 1 am exempt under Sec. Plan check fee B.BP.C. for this reason PERMIT ISSUING FEE$ Date: Signature TOTAL FEE 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 Professions Code):• - ❑ I, as owner of the property, or my employees with ADDRESS ( r•r•� a 37'1 v i 6 Q wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 33 131 r' y+,!■i30 7044, Business and Professions Code). OWNER ❑ I, as owner of the property,am exclusively contracting MAIL tion 7044, Business and Professions Code). � with licensed contractors to construct the project (Sec- ADDRESS �i /d� [ �VV 1 7"�]�j E IT 37 m0 CONSTRUCTION LENDING AGENCY CITY TEL NO. . �t 1_HEEL , 37■i[1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR LC S7Jol CHANGE ■00 (Sec. 3097, Civ. C.). Lender's Name ADDRESS y (_- ESTATE _ TEL. NO. 1 L '� [I31�1il—i {I11� ]r of}t=I Lender's Address 737131 • °t: / LIC. �l_n °=1TI certify that I have read this application and state that the E NO.. CLASS l/'�/ above information is correct. I agree to comply with all County -ordinances and State laws relating to building construction, and hereby thorize representatives of this County to enter m tion d property for in pecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Applicant or Agent 1 d�jDate Vh • WORKERS'COMPENSATION DECLARATI^N. -CEA 6 (2.80) 6 I�� ®p�I ®� UV p�� A364C I hereby affirm that I have a' certificate of consent to self I 'l insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING U a certified copy thereof(Sec.3800,Lab.C.) Policy Compan Certified copy is hereby furnished.y COUNTY OF LOS ANGELES BUILDING AND SAFETY El Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING /�/j 0 f). ,W77Wk department. C�7`7r /✓ J"L ,1 _ Date Applicant (PRINT OR TYPE ONLY) ADDRESS ,�(� LOCALITY moi/M t1/ / CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. O by the permit is for one hundred dollars (SIUU) oI less.) DISTRICT NO PROCESSED BY 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Ir permit is issued, I shall not employ any person in any manner ® O so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM •Z Exemption, you should become subject to the Workers' FINAL — 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 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 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. License Number Lic.Class Contractor Date I am exempt from the licensing•requirements as I am 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$ or Lic.or Reg.No. Date TOTAL FEE HOMEOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME al- License Law for the following reason (Section 7031.5, Busi- G ness and Professions Code): ADDRESS 64�zD /V c�U��/rl�� /V✓'� 5 4 8 0 A 1, as owner of the property, will do the work and the ^7�� structure is not intended or offered for sale (Section CITY ,�7r C:�/z TEL.NO.2��- � # 00000g 7044,Business and Professions Code). ❑ OWNER �^ I, as owner of the property, am exclusively contracting 2',, o2050 with licensed contractors to construct the project MAIL 6' A S -e2AW (Section 7044,Business and Professions Code). ADDRESS 7Cs✓ - 0'Q a 2 0.5 0 CONSTRUCTION LENDING AGENCY CITYS4V g,FA1�/Ee_ TEL.NO. ��j¢� I hereby affirm that there is a construction lending agency 0 9.22-83 for the performance of the work for which this permit is CONTRACTOR issuedttiSec.3097,Civ.C.). Lender s Name ADDRESS Lender's Address CITY TEL.NO. 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 NO. 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 up n the above-mentioned property for inspect, purposes. 9-Z 2 63 Signature of Permittee Date