HomeMy Public PortalAbout5530 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
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I hereby affirm that I have a' certificate of consent to self! CE-616(2-80) A P r®L ICAT I O N FOR PERMIT
insure, or a certificate of Workers'Compensation insurance,of I-IEATII�lG-VENTILATING-All2 CONDITIONING
certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with[the county building inspection FOR APPLICANT TO FILL IN A I L D I N
e/
Date Applicant (PRINT OR TYPE ONLY) _
LOCALITY
CERT FICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST---I-) % }
(This section. need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. / a0
by the permit is for one hundred dollars ($100) or less.)' DISTRICT-M- P OC ED BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner �/< O
so as a me s ject t*. .
r ens on Laws.' BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNAT E W
D Applica COMPRESSOR,BTU ROUGH iL
TIC TO A LICANTaking thisCertiftcate o' VENTILATION SYSTEM z
xem ion, you should becpme subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: DED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL LIV
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date
I am exempt from the licensing requirements as I am a
.licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
I
L ..or Reg.No. Date I TOTAL FEE 7410
1 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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I Xereby affirm that I am exempt from- the Contractors NAME
15cense Law for the following reason (Section 7031.5, Busi-
ness nd 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. - k,
j
7044, Business and Professions Code).
OOWNER 1`=i1+-
I, as owner of the property, am exclusively contracting _
with licensed contractors to construct the ro eGt MAIL +- ti=�T"
p ] ADDRESS 2 c -".I
(Section 7044,Business and Professions Code). '_ -�
CONSTRUCTION LENDING AGENCY CITY TEL.NO. "`.` I_.•�Il:
I hereby affirm that there is a construction lending agency .;ice:='I'
for the performance of the work for which this permit is CONTRACTOR -
issued Sec. 3097,Civ.C.).
Lender s Name ADDRESS
Lender's Address CITY TEL.NO.
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 LICENSE NO. CLASS I
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter us n the above-mentioned property for
e 'purpose . ,,•� /��
agnat e o rmittee