HomeMy Public PortalAbout5357 MCCULLOCH AVE_Mechanical__ ,., • 4P WORKERS'COMPENSATION DECLARATION + APPLICATION FOR PERM I T
14erekiy4irm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof(Sec. 3800, Lab. C.) 76A364C
/ � � r'�ry� CE-818(REV. 10/81)
PolicyNo Company-5/ 'y 6/
COUNTY OF LOS ANGELES BUILDING AND SAFETY
E] Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �• 7 /�� / Q,'r
tion department. ADDRESS r/ �i`G�/f�L7 �►7!/G
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
f����s��. 'PIX �f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' I 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
I certify that in the performance of the work for which this vvv
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. 'APPROVALS DATE INS t R' SIGNATURE
Date Applicant COMPRESSOR,BTU ROUGH r
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 VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU A ITY ✓
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
`(commencing with Section 7000) of Divisioh 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
,537/Ste. fti2 .1A11A 5 �vv
License Number-'5-37/ Class e-7—ry
QUT/�i7S �/STir✓l�� . ' u
Contractor A W- /T1j10 Date /� " RdTo Or
Ell am exempt under Sec. __. 307 30.50'u
Plan check fee IA
B.BP.C. for this reason, PERMIT ISSUING FEE$ ITEMS
Date: TOTAL FEE $-(� TOTAL 3-0. 50 ,
Signature CHECK 30.50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I 1E hereby affirm that I am exempt from the Contractor's License , , CHAN °0I
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property,'or my employees with ADDRESS 0000-0001 �� tf�g
wages as their sole compensation,will do the work and CITY TEL. NO. ?,`tM 8e 26
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
❑ I,as owner of the property, am exclusively contracting ewzu '
with licensed contractors to construct the project (Sec- MAIL 03 ��j'
tion 7044, Business and Professions Code). ADDRESS;
CONSTRUCTION LENDING AGENCY CITY TEL. N00I6
I hereby affirm that there is a construction lending agency for ,
the performance of the work for.which this permit is issued 'CONTRACTOR j 31
(Sec. 3097,Civ. C.).
ADDRESS'
Lender's Name '
CITY
Lender's Address
STATE LIC.
I certify that I have read this application and state that the 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
u the o ove entione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote