HomeMy Public PortalAbout5626 MCCULLOCH AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION
I Oreby'affirm that I have a certificate of consent to self ^• APPLICATION FOR PERMIT
insure; or;a certii'�ate of Workers'Compensbtion InsLirance, HEATING - VENTILATING - AIR CONDITIONING
or a certi`fed-copy thereof(Sec. 3800 Lab. C.) 76A364C
20-0046 DPW 9/88
PRIIcy. Nom ` l —=�ompany
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ANDSAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 6/_
tion department. p ) �! OR
ADDRESS IJP
Date 7f�-90 Applicant ////.�� yp l Wfl d1 1'l a wl (PRINT EQ TYPE ONLY) LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR ED BY
the permit is for one hundred dollars($100) or less.) of/
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFt r
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPE OR'S SIGNATURE
Date Applicant
COMPRESSOR, BTU 3 ��°� ROUGH
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 VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ov
I hereby affirm that I am licensed under provisions of Chaptdr 9 HEATER- SUSPENDED UNIT—
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and.effect. Tr �/f}
License Number Lic. Class , CL
O
Contractor L� 6w4rate 7-27-�� V
oe
❑ - I am exempt under Sec. V
Plan check fee
B.&P.C. for this reason C-
a e: !
PERMIT ISSUING FEE $ Z
Signatur �WN
r TOTAL FEE
�UILDERDE TION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): r
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. ACI`'T°g
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). , ,r[6 W. ,jjl
❑ I, as owner of the property, am exclusively contracting OWNER i ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 016 O °J TOTAL. 59 m 00
CONSTRUCTION LENDING AGENCY CITY r4jDTEL. NO. �/
I hereby affirm that there is a construction lending agency for �� _J Y&YYLCHECK 59.0-1.i
the performance of the work for which this permit is issued CONTRACTOR OM. CHANGE .130(Sec. 3097, Civ. C.).
D N
Lender's Name ADDRESS aq
CITY�2V rI j TEL. NO. O`7 -,P 7 / O�jI ICI-f_I�1 1 7/30/90
Lender's Address _
STATE 3� 3n' LIC. �s c -3,40
1 certify that I have read this application and state that the LICENSE NO.p( QS JV CLASS •>:105 X AM r°
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter "
the above-q ent' ed roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_
Z_::---A 7- 9
igna a Applican or Agent Date ®,