HomeMy Public PortalAbout5527 MCCULLOCH AVE_Mechanical__ WORKER'S COMPENSATION 'DECLARATION �5MDPW 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that'f have a;certificate of consent to self Insure,
or a ce;tifIcate of Workdr's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) 11
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ® BUILDING AND SAFETY DIV.
Certifled'copy Is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN AopREss�'��'
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY��e
NO. TYPE'OF APPLIANCE OR EQUIPMENT FEE ~/
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE
ABSORPTION UNIT CROSS.ST.BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK ��� PAGE,QVp PARCELQ1j'1
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
•
I certify that in the performance Of the work for which this permit DISTRICT NO. PROCES
is:issued, I shall not employ any person in any manner so as to BOILER,BTU Q s
-become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE PECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM '
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH ,16414
Exemption,you should become subject to the Workers'Compensation 'EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. r FURNACE: FAURAVITY
LICENSED CONTRACTORS DECLARATION Q FLOOR BTU m 474PIM VALIDATION 7'
•1 hereby affirm that I am.licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL I
Professions Code,and my license is in full force and effect. I TEES
TOTAL 90.40
License Number Lic.Class / p� , CHECK 30.40 =
Contractor Date CHANGE ' .00 C
El ani exempt under Sec. Plan Check fee a
B.&P.C,for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE :11� t�lp f 496 1 PM r°}�` n
Signature PLAN CHECK APPLICANT U,
OWNER-BUILDER DECLARATION "' y�' 2
1 hereby affirm that I am sxempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS CU/ O
❑ I, as owner of the property, or my employees with wages '
as their sole compensation, will do the work and the CITY TEL.NC;�,11�e C-7
structure is not Intended or offered for sale(Section 7044,
Business and.Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044;Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit s issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. CLLA�SS
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
pro arty for inspecfi n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
G ATURE OF APPLICAI OR AGENT DATE
WORKER'S GOMPENSATIONDECLARATION 200046 DPW 9189 APPLICATION FOR PERMIT `IME GREEN
hereby..effi�rm that I�have a certificate of consent to self insure, � ��
or cefJfficate of%korler's'Compensation Insurance, or a certified-A HEATING-VENTILATING-AIR CONDITIONING
copy therepf(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. BUILDING
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS S y�J
ABSORPTION UNIT,BTU ASSESSOR
p p
(This section need not be completed if the work Involved by the MAP BOOK C t5V.3 PAGE PARCEL QDS
permitds for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manna so as to BOILER BTU
become subject to the Workers'Comp ti
Laws. • C�ir/G
C COMPRESSOR.BTU
Date �✓ A licant APPROVALS GATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM //
NOTICE TO AP OCANT: If, of to of ROUGH
s{ -
Exemption,you should become subjectthe or,_�ers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwi(h comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 'VAID TI N
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT q
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license Is in full force and effect.
License Number 6� Lic.Class HC's:I a
3303 32S.55
Contractor Date y C. Q
❑ Plan check fee ( - ITEMV
Is exempt under Sec. 3 3—_
TO!rpt_ _55 t=E- E lI
B.&P.C.for this reason PERMIT ISSUING FEEQ
,, X 3 ,._
y' TOTAL FEE Q LL
SignatAreasoo
Y, (s�-IAINGE .011
1i i a
PLAN CHECK APPLICANT fl
z
I hereby affirmpt from tShe ontractor's License Law ,NAME , .'I `"1`i'`"'
for the followion 70321.5, Business and Professions i'l EI'I��'(�" 'ff i'}f
CodEl e): �i}ti i° t'
I, as owner of the property, or my employees with wages
as their sole compensation, 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 MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). i
CONSTRUCTION LENDING AGENCY iCITY r!> TEL.NOs �� Z
I hereby affirm that there Is a construction lending agency for CONTRACTOR 11110.the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
,CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to builring construction,and hereby authorize
representat' s of this ou y to enter upon the above-mentioned
proper •InspActi• poses. G SEE REVERSE FOR EXPLANATORY LANGUAGE
ri S l
SI ENT AT