HomeMy Public PortalAbout5612 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm+that I have a certificate of consent to self
insure, or a certificate of Workers'CompensationWIns:ura�n,, HEATING - VENTILATING - AIR CONDITIONING
or a cetified cop thereof (Sec. 3800, Lab. C ) 76A364C
6/��0[ �/,� ey/ c A CE-818(REV. 10/81)
Policy No.WCompany J
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /�✓��
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date a Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /
COMPENSATION INSURANCE CROSS ST. is
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE PpTOR'S SIGNAT RE
1 COMPRESSOR, BTU NO 6&0 D ROUGH ti r
Date Applicant —
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with.comply with such provisions or this permit shall be le
deemed revoked. FURNACE: FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU Gb-IK
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business I - WALL i
and Professions Code,and my license is in full force and effect.
3 _License Number ?o Lic. Class 7`6 W
Contractor Date 60—x r�0 O
❑ 1 am exempt under Sec. 21 01,8A w
Plan check fee # a a o a 8 IL
B.&P.C. for this reason' U)
PERMIT ISSUING FEE$ I1- - 4625
Date:
TOTAL FEE
Signature o 0 - 116256
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
I, as owner of the property, or my employees with ADDRESS
El
j 0.27-88
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY B TEL. NO.
7044, Business and Professions Code). OWNER C��-�+-
❑ I, as owner of the property, am exclusively contracting MAIL �/• 00 9
with licensed contractors to construct the project (Sec- ADDRESS 'Z/—
tion 7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY CITY TEL. NO. rj 7g 37y
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued a
p P CONTRALTO
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name a
CITY TEL. NO. Z/
Lender's Address
STATE LIC.
1 certify that I have read this application and state that the LICENSE NO. T�� O CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
an hereby authorize resentatiesvCounty to enter
up n
;:7rAU p�erty for inspection
1purrpoosses. SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Applicant or Agent Date