HomeMy Public PortalAbout5322 MCCULLOCH AVE_Mechanical__ WORKERS'�:ONIPENSATION DECLARATION
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APPLICATION FOR PERMIT w ; ;
I hereby affirr+li-"Lhbt I have a certificate of consent to self r
-1 insure, 9r•a iiertificate of Workers'Compensation Insurance;, BEATING - VENTILATING - AIR CONDITIONING
or a cert' ied copy thereof(Sec. 3800, L ) 76A364C
CE-818(REV. 10/81)
Policy ..ompany
❑ Certified copy is hereby furnished. COUNTY OF'LOS ANGELES BUILDING AND SAFETY
JA J
® Certified copy is filed.with the co my building irl4pec FOR APPLICANT TO FILL IN BUILDING
tion)apart ent: ADDRESS '� •
(PRINT OR TYPE ONLY) .
Dat Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
C IFICATE OF EXEM ON F WORKERS' NEAREST
COMPENSATION IN ANCE CROSS ST. /
(This section need not be complete If the work involved by ABSORPTION UNIT,BTU DISTRICT NO. T PROCESSED BY
the permit Is for one hundred dollars($100)or less.)
I certify that in the'performance of the work for which this AIR HANDLING UNIT,CFMo ti
permit is'issued, I shall not employ any person in anti.manner•
so as to become subject to the Workers'Comperisation Laws. BOILER,:BTU APPROVALS DATE IN PE S51 ATURE
Date Applicant COMPRESSOR,BTU ROUGH 97
NOTICE TO APPLICANT: If,. 'after making this Certificate of VENTILATION SYSTEM ' FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you-must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be.
deemed revoked. FURNACE:, FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR ' BTU (J
I hereby affirm that I cim licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business - WA1
and Professions Code,•and'my license is in full force and.effect. Q
Lic ns Number Lic. Classes f�1H �'� 67
,r Date ® ( 4
❑ ° ° 007 Z .
rap.d.
exempt r Sec. WPlan check fee H foris reason PERMIT ISSUING FEE$ o 0 o a$,0 0 v
Date:.
Signature
`TOTAL FEE ( (a 7_g'] .
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 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 `
wages as their sole compensation,will do the work'and "CITY TEL.NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct-the project (Sec- MAIL
tion7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CIT ` TEL. NO.
I hereby affirm that there is a construction lending agency fdr, •
the performance of the work for which this permit is,issued CONTRACTOR
(Sec,;3097, Civ. C.).
ADDRES
Lender's Name 1
CITY A TEL. NO. -
Lender's AddressAl
that Ihave read this application and state that the STAT. LI
I certif ' C.
y pp LICENSE NO. CLASS
above information is correct,.I•agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize represent of this County to enter '
upon th ve.- ntioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A cant or Agent to