HomeMy Public PortalAbout6439 SULTANA AVE_Mechanical__ HORKERS COMPENSATION DECLARATION = 76A364C APPLICATION �FOR PERMIT - �
1 hereby affirm that 1 have a certificate of consent to self CE 81817801
insure or a certificate of Workers Compensation ran 0 HEATING-VENTILATING-AIR CONDITIONING
ace, III d cf.�therP f Sec 3800 Lab C ) '
NJ %4 ,o ,mpany ` O M •Zw/S
❑ Certified copy IS hereby furnished /..�-�/a COUNTY OF LOS ANGELE� BUILDING AND SAFETY
Certified copy w filed with tht.,counts budding inspection FOR APPLICANT TO FILL IN �../ BUILDING � S C_TAN
department ADDRESS
Dao fQ='2c.Z��p plicant % (PAINT OR TYPE ONLY)
!—�
LOCALITY T5 PLE CI T y
CF RTII'ICATF OI FXEAtPTION I'ROht WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST y
(This section need not be completed If the work Involved _ _ _ ABSORPTION UNIT BTU - - _ _ CROSS ST -_ - - —oil by the`pertnit-is for one hundred dollars ($100) or less) - DISTRICT NO PR r SS, av (�
I certify that In the. performance of the work for which this AIR HANDLING UNIT CFM—
permit
FM permit IS issued 1 shall not employ any person in any manner
so as to become subject to the Workers Com pensuhon Laws BOILER BTU
- APPROVALS DA E INSPECTOR SSIGN� ARE W
Date Applicant COMPRESSOR BTU_ ROUGH 2^7� y
NOTICE TO APPLILANT If after making this Certificate of VENTILATION SYSTEM
}xcmption you should become subject to the Workers FINAL
Com pcompl n with
slomuch of the Labor Code you must forth EVAPORATIVE COOLER DATION
with comply with such provisions or chit permit shell be
deemed resoked FURNACE FAU— GRAVITY
LICI NSLD CONTRACTORS DLCI ARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Doislon 3 of the Bus, WALL 3',�'pop
nes% and Professions Codc and my license is in full force and T—
effect 7/ _
License Number_ Lic Class-9- /
r
Contractor Date A0 17-9/ '
❑ 1 am exempt from the licensing reymrcments as I am a
hcenscd architect or a registered professional engineer Plan Check fee 25%of above _
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE S
Lic or Reg No Date - TOTAL'FEE Z
HOME OWNER BUD DLR DECLARATION PLAN CHECK APPLICANT -
1 hereby affirm that I am exempt from the Contractors NAME/
License Law for the following reason (Section 7031 S Busl
ness and Professions Code) ADDRESS
❑ I as owner of the properly will do the work and the /
structure is not intended or offered for sale (Section CITY� Kp�C CiT�f TEL NO�g71 37
7044 Business and Professions Code) !! -
OWNER Ti A - f 1.6 9 6 A
❑ 1 at owner of the property am eXCIUSJ%LIY contracting _ T
with licensed contractors Pr construct [) project ADDRESS 6_yJ p SL/e r�'�h �! I
AIL
(Section 7044 Business and Professions Code) r_ I• � � � � 8
CONSTRUCTION LI NDING AGENCY CITY.,,7- //�. C'fT/ TEL NO 2 0 0 1 7 O O
1 hereby affirm that there IS a construction lending agency �r CC�- �T 7
for the performance of the work for which the permit ,s CONTRACTOR G��(/B ZA Lk.V Alm OO ,�i� 1 7.006
issued (Sec 3097 Cn C ) / r
Lender s Name ADDRESS C?/Z/ `O,vG DFS u I
Lender s Address Q 2 7• 8 1
CITYl"E�P�� TEL NO
1 cunt) that I have read this application and state that the STATELIC 8
above Information IS correct 1 agree to comply with all County (CENSE NO eae 2 -CLASS`
ordinances and State laws regulating Heating Ventuatmg and -
Air Conditioning and hereby authonic represcntativcS of this SLL REVERSE 1 OR EXPLANATORY LANGUAGI•
Count) to enter upon the abose mentiOncd property for
m� Non pur5 _ - - •
Signature of Permittee Dale