HomeMy Public PortalAbout5414 A & B MCCULLOCH AVE_Mechanical__ ,W.OR-KERS'COMPENSATION DECLARATION ^ " t I CEA 8 SC(2-SO) A P P L ICAT I O N FOR PERMIT
I hereby affirm that I have a' certificate of consent to self
inure; or a
cer ' i to �Wmpenstion Insurance,or HEATING-VENTILATING-AIR CONDITIONINGopy � l
I
olicy NO.. Company
❑ CMified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
djartmen . ADDRES
-/-�
Da Applicant A - (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G°
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is .for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED IL
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM .�^�
permit is issued, I shall not employ any person in any manner v cc
so as to become subject to the Workers'Compensation Laws. BOILER,BTUO
APPROVALS DATE INSPECTOR'S SIGNATURE
►Date V
Applicant COMPRESSOR,BTU ROUGH /Oi�2J p^ '- a
Nu'ICE TO APPLICANT: if, after making this Certificate of VENTILATION SYSTEM FINAL �'!�1^p� �' z
Exen,j.-Ion, you should become subject to the Workers' _
Compens,.ion provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect. ()
License Number Lie.Class
Contractor Date
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%oigbove.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ `7
Lic.or Reg.No. Date TOTAL FEE
HOME OVANER-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).
El 1,
I, as owner of the property., am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.N1546Qv :2228 1 A
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is (� # o 0 o o 4 1
issued(1Sec. 3097,Civ.C.).
Lenders Name ADDRESS 2 0 o47,00
Lender's Address CITYTEL.NP2/j{
I certify that I have read this application and state that the STATE LIC. o 0 0 7.00
above information is correct.1 agree to comply with all County LICENSE NO. CLASS 9.25-80
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-mention darty arty for
inspect( purp s
igna ure of Permittee Date