HomeMy Public PortalAbout5528 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATIONCEA Ss g (z.gp) APPLICATION FOR PERMIT
1 hereby affirm that 'I have a' certificate of consent to selfi,.
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company
Certified copy is hereby furnished. ( COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with thecounty building inspection [ADD
UILDING
department. FOR APPLICANT TO FILL IN /^
Date Applicant (PRINT OR TYPE ONLY) 7FE
RESg=g,
OCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT
COMPENSATION INSURANCE EA(This section need not be completed if the work involved ABSORPTION UNIT, BTU ROSS ST. �- a
by the permit is for one hundred dollars (5100) or less.) DISTRICT_W PROPESP6 BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM CJ
/►y
permit is i ued, 1 shall not employ any person in any manner.. — 6
so as t eco e s bject to the W ers' o pensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATU E V
of
Date Applicant COMPRESSOR,BTU ROUGH d
NO CE O A PLICANT: after making this Certificate f VENTILATION SYSTEM FINAL 2
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-
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 above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$1191
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 Code): ADDRESS _92/1. as owner of the property, will do the work and the CITY TEL.NO. --
structure is not intended or offered for sale (Section .:+_
44, Business and Professions.Code). I
OWNER ,• hi`t=;
Vas owner of the. property, am exclusively contracting "
with licensed contractors to construct the project MAIL ;. �:`� _ �?++ 511)
(Section 7044, Business and Professions Code). I ADDRESS
CONSTRUCTION LENDING AGENCY ! CITY TEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit!is CONTRACTOR
issued iSec. 3097,Civ.C.).
Lender s Name ADDRESS
-.-.
CITY TEL.NO.
Lender's Address —;,r ., 'r!`
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County I LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and l
Air Conditioning, an hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enF-e
p the above-mentioned property ,for
or
' n purp
i
V
ign ur o ermittee ate