HomeMy Public PortalAbout5412 A & B MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATIQN. A a BC(2-BO) APPLICATION 1=O R PERMIT
I-hereby affirm that I have a' certificate of consent to self CE
insure, o�ri,ac certificate of Workers'Compensation Insurance,o'r HEATING-VENTILATING-AIR CONDITIONING
a cerYfj Lk��of �.j8�,l a u
olic IL�I0. `O o
Pm�p%any
Certified copy is hereby furnished. i COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building in ection BUILDING
epartm nt. r„� FOR APPLICANT TO FILL IN J
Dat 'YS�pplica � �-� (PRINT OR TYPE ONLY) ADDRESS � /
LOCALITY G
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST a
by the permit is for one hundred-dollars ($100) or less.) DISTRICT N6. PRO SSED e V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU ROUGH �� 5� -- GW
-
NOTICE TO APPLICANT: If, after making this Certificate of to
VENTILATION SYSTEM FINAL Ara" '-�. Z
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS.DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date
• I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of gKove.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ 7
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the CITY TEL.NO.
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 MAIL
(Section 7044, Business and Professions Code). ADDRES
CONSTRUCTION LENDING AGENCY CITY TEL.NO. Z 8 2 P.
I hereby affirm that there is a construction lending agency CONTRACTOR # 0 0 0 0 [j
for the performance of the work for which this permit is G
issued(Sec.3097,Civ..C.).
Lender's Name ADDRESS 2 - 4700
Lender's AddressCITY TEL.NO Lz< 0 0 0 ! IJ
I certify that I have read this application and state that the STATELIC. J�
above information is correct.I agree to comply with all County LICENSE NO3. 2 CLASS 2 V q 2 5-
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned prop ly for
iuspeon pur S.
>gnature o ermittee Date