HomeMy Public PortalAbout5444 MCCULLOCH AVE_Mechanical_9/30/1992_ ION
WORKER'S I have
a certificate
of consent to 20-0046 DPW
PW9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate aT consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. B DING
F1Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDR SS J%7 L G(!L _c)Ce
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS b)ql /�JES
COMPENSATION INSURANCE ,y
ABSORPTION UNIT,BTU ASSESSOROR` �/
(This section need not be completed if the work Involved by the MAP BOOK PAGE /—/I PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the wDISTRICT NO. PROCESSED BY
ork for which this permit -
is issued, I shall not employ any person in any manner so as to BOILER BTU
become subject to the Workers'Compensation Laws. !J
0- �� �� � COMPRESSOR,BTU APPROVALS DATE INSPECT S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL -- "
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU V LIDATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class L XJ/ e"
Contractor Date C
❑ f 1•-
I am exempt under Sec. fa�
Plan check fee •.:C • -+.- Q
B.&P.C.for this reason PERMIT ISSUING FEE$ tij 31K 7 2E.='S C
CIO
Date: TOTAL FEE g ' 'L'(= C
Signature TOTAL
;L
OWNER-BUILDER DECLARATION PLAN CHECKAPPLICA 2
1 hereby affirm that I am exempt from the Contractor's License Law NAME , CHECK
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS-
❑ 1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. { �l_-1 3 ,1
structure is not intended or offered for sale(Section 7044, -�=L'= ti-�- 7LL•r �
Business and Professions Code). OWNER 5r_`2 a AM � a�7
F1 I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for ONTRACTORJ � 77 � ��
the performance of the work for which this permit Is issued 0#A) ,
(Sec.3097,Civ.C.). _
ADDRESSc
Lender's Name �/�PL� C L10/ 0777
CITY TEL.NO. i
Lender's Address STATE G LIC.
I certify that I have read this application and state that the above LICENSE.NO./� L CLASS
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 the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE