HomeMy Public PortalAbout5324 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I,herpby affirm that-.) have a certificate of consent to self
insure, or a.c?Etificate of Workers' C,Pmpensation Insurance,
ord�Ptified copy thereofpc'.��
(S380(�Lab. C.) 76A364C - t. HEATING - VENTILATING - AIR CONDITIONING
20-0046 DPW 9/88
Po'licy►No.• Company
❑
Certified copy is hereby Nrnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ` 1-
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �' �C C U
tion department. ADDRESS��
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY ;'M (�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE 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. > PR�EDB
the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this 1�
permit is'Issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to,the Workers'Compensation Laws. APP" DATE' SPECTOR'S SIGNATURE
Date Applicant ' COMPRESSOR, BTU 0 ROUGH �
NOTICE TO APPLICANT: If, after'making this Certificate of VENTILATION SYSTEMFINAL -
Ou ` ,,
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
•with comply with such provisions or this permit•shall be deem-
ed revoked. FLOOR
CE: T GRAVITY
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I•am licensed under provisions of Chapter 9 HEATER: SUSPENDED _UNIT
-
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect. �1
• d
License Number Lic. Class F , O
u
Contractor Date
0 , I am exempt under Sec. V
Plan check fee u,
B.$P.C. for this reason IL
PERMIT ISSUING FEE $ Z
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): iz
ADDRESSJam.
F-1 iL ne "I
, as owner of the property, or my employees with
wages as their sole compensation,will do the work and CITY r 1 �� TEL. NO. ^w80�' Alf T°g
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER3307 '59.011
❑ I, as owner of the property, am exclusively contracting 0`� C��� Ai�� 1 ITEMS
with licensed contractors to construct the project (Sec- ADDRESS j
IL
tion 7044, Business and Professions Code). - TOTAL. 59.0101
CONSTRUCTION LENDING AGENCY CIT TEL, NO.
1 hereby affirm that there is a construction lending agency for CHECK 5 ,11 •
the performance of the work for which this permit is issued CONTRACTOR t( , A!i�3E .00(Sec. 3097, Civ. C.).
12 Lenders Name (-�dtMP SO 1/1 OU�S l� • ADDRESS
COO F. f�U N 'h N C�'b f� (�{• CITY TEL.NO. 0000-0001 8/2.4/' 0
Lenders Address [STATELIC. 2557 1 AIS u-0[14
I certify that I have read this application and state that the CENSE NO. CLASS
above 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Je,,Z-__.- oO- a 3.-40
Signature of Applic t or Agent Date