HomeMy Public PortalAbout5608 MCCULLOCH AVE_Mechanical__ �'.�TIRKLRN C'0?%I11LNSATION DEC'LARA f1ON CEA 81 8 (2-80) A P P Lam.f.LCA : �O N' F®R PE R Wu
)I lzrei`y•afffr- that I have a' certificate of consent to self
insure,or a certificate:of Workers'Compensatio Insurance,or I HEATING-VENTILATING-AIR CONDITIONINGa certified copy thereof(Sec.3800,Lab.C.)
Policy No. _company .4/ '
'Certifi•,I -opr is hereby furn'c.._ COUNTY OF LOS ANGELES BUI I G NDS FE
LL�d u,p I,fl •(I wit.l the ounty huildir t inspection BUILD Li
Da.p rtmt tit ,�- FOR APPLICANT TO FILL IN
_ �_ ++lira t e� (PRINT OR TYPE ONLY) ADD S
LOCALITY
'I:R'rlFl( k71.;UI EXEMPTION FROM WORKERS' � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(;Iris section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a
by the permit is for one hundred dollars (S100) or less.) , DISTRICT NO. PROCESSE v U
I certify thit in the performacce of tire work for which this I AIR HANDLING UNIT,CFM
parrn:t is issued, I shall not employ any person in any manner �� 0
O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
/aa V
APPROVALS DATE INSPECTOR'S SIGNATURE
Uatc _. %pplit:ant f COMPRESSOR, BTU V ROUGH d
NO'r1C'F TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z
'.%emptirtn, you should become subject to the Workers'
Compensation provision% of the Labor Code, you must forth- I EVAPORATIVE COOLER VALIDATION
Nvith comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGR V TY
I.ICI:NSIED CONTRACTORS DECLARATION I FLOOR: 97 &2 `Z 2--
I
I Itt.reh! affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencinS with Section 7000)of Division 3 of the Busi- WALL
ves and Profeksions Code, and my license is in full force and l
t•ffcct.
Lici--sq,Nulnoe._ 1—/ _
L' lass
Co,. r:,,•,.... Date
Irl I am c.elnpr from the licensingr uirements as Itma
licensed .trchitvct or a registered professional engineer i Plan check fee 25%of above.
acting in my .professional capacity (Section 7051, Bus-
iness and Professions Code).
Lie.or Reg.Nay._ Date TOTAL FEE -
110ME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm, that I am exempt from- the Contractor's NAME
License Lave for tire following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
D I .
1, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project , MAIL ( t? r; fj n
(Section 7044, Business and Professions Code). ( ADDRESS C
CONSTRUCTION LENDING AGENCY + C'TY
TEL.N0.3 0 0 0 0. o l•
I hereby affirm that there is a construction lending agency 3
fur the performance of the work for which this permit is CONTRACT o o j 7 !;
issued (Sec.3097.Civ.C.). t`
Lender's Name ADDRESS v �J Coe
Lender's Address CITY c EL.NO. Lla— 24- 1
1 certify that I have read this application and state that the STATE �,/Q► LIC. c_
,t shove information is correct.1 agree to co ply with all County LICENSE NO. 9 CLASS
ordinances and State laws regulating Heati tg, Ventilating and
Air Conditioning.and hereby authorize re resentatives of is SEI: REVERSE FOR EXPLANATORY LANGUAGE
Cuunty to _, a^ur, he above- er.toncper
IncpeCtion •n•l+.ts�_ � �
�:Cr+ii,ure c `'t'. t.� Date