HomeMy Public PortalAbout5620 MCCULLOCH AVE_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 20-0046DPW 9189 APPLICATION FOR PERMIT U E GREEN
78A384C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATIN -VENTILATING-AIR CONDITIONING
copy t (Sec.3800 Lab.C.) •y
Policy No. 7 COmmpany � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
UILDING
Certified copy is filed with the county buil di nspeotton FOR APPLICANT TO FILL IN PDDR SS L
departmentnt/// (PRINT OR TYPE ONLY)
Date �` ' Applicant (/�. LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT.BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,BTU ✓
become subject to the Workers'Compensation WS.
n COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant ( VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after ma ng this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL Gt
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: S NDED UNIT
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect.
License Number Lic.Class Jd/ G
® a
Contractor A&.;- Date �� �� C
Plan check fee
❑ I am exempt under Sec. Q
B.&P.C.for this reason PERMIT ISSUING FEE$ a L
Date: TOTAL FEE ; Cf a
Signature Cr
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ID
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions ® y °V 48.90
o �
Co48e): ADDRESS U j °7Q
I, as owner of the property, or my employees with wages �!
as their sole compensation, will do the work and the CITY TEL.NO. 1 ITEMS
structure is not Intended or offered for sale (Section 7044, ^ f5 A�TAL 48.90
Business and Professions Code). OWNER / J� TO
❑ I, as owner of the property, am exclusively contracting MAIL y—� CHEC{ �7 4a°90
with licensed contractors to construct the project (Sec- ADDRESS ilG
tion 7044,Business and Professions Code). CITYJ� TEL.NO. L 5 CHANGE °00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending,agency for CONTRACTOR "OPPeC.%
the performance of the work for which this permit s issued e [f(Seo.3097,Civ.C.). tJ7/25/75
Lender's Name ADDRESS � ��/�® �y(C i AHipoS0
CITY K!r� TEL.NL`rJ a t5]�1Lender's Address STATE LIC.I certify that I have read this application and state that the above LICENSE NO. Z CLASS ,
information is correct. I agree to comply with all County ordinances
XStatews relat' to building construction,and hereby authorize
ves his County to enter upon the above-mentioned
r' action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLICANT OR AGENT DATEfY