HomeMy Public PortalAbout5346 MCCULLOCH AVE_Mechanical__ 1COMPENSATION DECLARATION APPLICATION FOR PERMIT
Ther >. ERV
imthat I have * certificate of consent to self
insure, erficate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A3640
CE-818(REV. 10/81)
1 Policy ko. Company
❑I#Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑d Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING A A G
tion department. (PRINT OR TYPE ONLY) ADDRESS 5AA
34
Date! Applicant, LOCALITY
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. PROCESSED BY
the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM ' V
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 become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE I P TOR'S SIGNATU E
COMPRESSOR,BTU id COROUGH
Date ( MApplicant'
NOTICE O APP ICA T: If, of r making this Certifi a of VENTILATION SYSTEM FINAL /
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER forth- VALID O
with comply with such provisions or this permit shall be .
deemed revoked. } FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT a
'(commencing with Section 7000)of Division 3 of the Business - WALL y,
and Professions Code,,hand my license is in full force and effect. IL
License Number 'Z! Y L Lic. Class �, , u
apA�//��//��,�� @9
Contractor 1N'IILt. AkE7 Date ( i � 11—
❑ I am exempt under Sec. r I.
Plan check fee �
BAP.C. for this reason PERMIT ISSUING FEE$ [) Z
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT J44s. '
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):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCT-.V&'
the structure is not intended or offered for sale(Section CITY TELNO:
307
7044, Business and Professions Code). �6 ,0 ®� ,
OWNER 1 ITIM 464
2
❑ I, as owner of the property,am exclusively contracting MAIL +�
with licensed contractors to construct the project (Sec- ADDRESS (�i TOTAL 2
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY clrY eA TEL. NO. GECn 46475
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued • CONTRACTOR , r» � 000
(Sec. 3097, Civ. C.). _
ADDRESS 0000-0001 6116189
Lender's Name �e GU ��j9 t i
CITY /K/ TEL. NO.SIR' YT`s�, 4024 1 AM11..34
Lender's Address
I certify that I have read this application and state that the STATE LIC. n h
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 representatives of this County to enter
upon t e above-mentioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant o Agent 7 Date