HomeMy Public PortalAbout5313 MCCULLOCH AVE_Mechanical__ ION
WOthat I have
a certificate
of consent to 26A346DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
7BA3e4C
I hereby affirm that I have a certificate of consent to self Insure, �7
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING `IILII�
copy there (Sec.3800 Lab.C.)
Policy NA&e19 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. q��J, c - (PRINT OR TYPE ONLY)
Date �—Z�� Applican � ;Z CSD LOCALITY .7�
I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU �G7f +
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY / t VA A ION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
—
(commencing(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
X / ev
License Numbers 2 Lic.Class
Contractol10 2uOXASt7W415Date
❑ 1 am exempt under Sec. Plan Check fee Q
B.&P.C.for this reason PERMIT ISSUING FEE$
C
Date: TOTAL FEE
Signature PLAN CHECK APPLICANT V
OWNER-BUILDER DECLARATION G
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not Intended or offered for sale (Section 7044, 3301
Business and Professions Code). OWNER
F1 I, as owner of the property, am exclusively contracting I1=�'
MAIL 0
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With licensed contractors to construct the project (Sec- ADDRESS '�'0 i AL 53o 5J,
tion 7044, Business and Professions Code). CIN TEL.NO. 'I/ +,i]i
CONSTRUCTION LENDING AGENCY CHECK
I hereby affirm that there is a construction lending agency for
I performance of the work for which this permit is issued CONTRALTO / ��� S , (. liNib E e_jy(
(Sec.3097,Civ.C.). �`�
/�_ `yL i � vxz!
Lender's Name r
,,�Q CITY �'- d� TEL.NO. � l�lj( l�••-I�.l 11��, f!%�j%'f
Lender's Address�Z� ��'✓ ►���1� W�y��� STATE LIC. 7 AM
1 certify that I have read this application and state that the above LICENSE NO. CLASS L'g
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for i pection r. ses. 7_1
1 / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUREF APPL OR AGENT (r//�, DATE