HomeMy Public PortalAbout5312 MCCULLOCH AVE_Mechanical__ w1M1lORKER'SCOMPENSATION DECLARATION 200048 DPW 9/88 APPLICATION FOR PERMIT LIME GREEN
76A364C
I heEpby affirnrthat I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Companl COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ 1
Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
NT OR TYPE ONLY) ADDRESS
department.}� /� : (PRI �
Date " ,,C�—Applicam +QVC LOCALITY �s
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAEST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. ,
COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU f�
become subject to the Workers'Compensation Laws.
/ COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: if, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUGRAV
LICENSED CONTRACTORS DECLARATION FLOOR BTU lo-z'tT V A ION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-- UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license Is in full force and effect.
-- , r,
�p
License Number ✓�! Lic.Class
CL
Contracto
E�AJS" OC9 mate , V
ElI am exempt under Sec. Plan Check fee Q
BAP.C.for this reason PERMIT ISSUING FEE$ .3.1'-IC' C
Date: TOTAL FEE (j,f
Signature a
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions , 3
Code): ADDRESS
ElI, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. VLI�! ti�_I�)jjl
structure Is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER ITP
F1 I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS TOTAL
AL !T.Z. m��
tion 7044.Business and Professions Code). r
CONSTRUCTION LENDING AGENCY CITY TEL.NO. CHECK I='
I hereby affirm that there is a construction lending agency for CONTRALTO , CHANGE °Ifll
the performance of the work for which this permit s Issued
(Sec.3097,Civ.C.).
dj ADDRESS _
Lender's Name 7
T r CITY �v� TEL.NO /% [)_Illfj—iifi4t?� r . 1,`�i
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. � CLCASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represent lives of this County to enter upon the above-mentioned
proper1.
ty or Inspeca0 -170
sea. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN URE OF APPLICANT OR AGENTDA E