HomeMy Public PortalAbout5416 A & B MCCULLOCH AVE_Mechanical__ WORKEJ�S'COMPENSATION•DECLARATION, CEA 918C(2-80) A P P L ICATION FOR PERMIT
I hereby`ai'firm that I have v certificate of consent to self
insure, or a certificate of Workers'Compensation Ins once,or HEATING-VENTILATING-AIR CONDITIONING
JaceeWii g�_. Commpanyj J
Certified copy is hereby furnished. , COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection01
department. FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) ADORES
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }d
(This section need not be completed if the work. involved ABSORPTION UNIT, BTU CROSS ST.i, 15 O
by the permit is for one hundred dollars (5100) or less.) DISTRICT ke. PR SED BY U
I 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 $ O
so as to beco a subject to the W kers'C mpensation Laws. BOILER,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date App lice COMPRESSOR,BTU ROUGH ' v CD
NOTICE TO APPLICANT: If, after making this Certif(cate f VENTILATION SYSTEM FINAL •Z' r 141 �— 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 chec fee 5%of alfove. _
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ _
Lic,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 Cods): ADDRESS
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO.
7044,Business and Professions Code).
I, as owner of theOWNER
property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS 2 2 0 A
CONSTRUCTION LENDING AGENCY CITY TE �aD�
I hereby affirm that there is a construction lending agency ft 0 0 0 0 4 1
for the performance of the work for which this permit is CONTRACTO AIC
issued Sec. 3097,Civ.C.). 2 ° - 4700
Lender.s Name ADDRESS
Z/�3 ° ° ° 47,OOU
Lender's Address CITY TEL. -
I certify that I have read this application and state that the STATE r LIC. (] 0,2'5—8 0
above information is correct.I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Heating,Ventilating 'and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ente upon the above-mentioned property for
n pur
i
Sig at a of rmittee Date
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