HomeMy Public PortalAbout5632 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
1),h
sure,
gffi�m that I have a certificate of consent to self
�i�isure,or.a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
-or a'certified copy thereof(Sec. 3800, Lab. C.) C
CE 818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESI3
Date Applicant 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. PROCESSED BY
the permit is for one hundred dollars(;100)'or less.) `/%
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �JY
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'CompDensdation Laws. f BOILER,BTU J� APPROVALS DATE �s TOR•s SIGNATI�E
Date �� pplirsu� � ! COMPRESSOR,BTU il ROUGH j � z1 �!
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 VALIDATIhFJ V
with comply with such provisions or this permit shall be
deemed revoked. / FURNACE: FAU VIT
LICENSED CONTRACTORS DECLARATION ! FLOOR B7U
I hereby affirm that I am licensed under'provisions of Chapter 9SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions.Code,and my license is in full force and effect.,
License Numb e �2 Lic. Class
/ �7/'
Contrl7 t �/y Date�' / y # b 3
❑ I am exempt under Sec. W
Plan check feeI 3 Q 5 0 N
o
B .BP.C. for this reason' `o
Date: PERMIT ISSUING FEE$ 5 a a a 3(15.0 55
Signature
TOTAL FEE 0 7,;'o 9 8 7
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Poo.Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with , ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER
El1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR G
(Sec. 3097, Civ. C.). _ w
ADDRESS
Lender's Name. ����
CITY. TEL. NO.
Lender's Address
E �� / LIC.
I certify that I have read this application and state that the LICENSE NO. FJ �� CLASS C Z D
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
:5?4�
operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7_ /'- F-Z
Signature of Applicant or Agent Date