HomeMy Public PortalAbout5632 1/2 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self ' APPLICATION FOR PERMIT
*Insure, ora certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or o'ce;tlfied,copy thereof(Sec. 3800, Lab. C.) _ 76A364C
CE-818(REV. 10/81)
Policy No.' Company
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. ADDRESS
• (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. AA
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED
the permit is for one hundred dollars($100)or less.) o///
AIR HANDLING UNIT,CFM
1 certify that in the performance of the work for which this (�
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws., APPROVALS DATE IT 70R'S SIGNATURE
DatJ��P_�7 Applica t• �f�iJt ® ' COMPRESSOR, BTU ROUGH j/ j / �G(� '`r l47
e� 7
NOTICE TO APPLICANT: If, after 'maling this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit'shall be
deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. IL
IL
License Number���Fi �Z—Lic. Class 7—.0
c @7432A p
rco Date o�o00og b
I am exempt nder Sec.
a'a 34150 w
Plan check feeo,a�o.3 4 5 p v y
B.BP.C. for this reason'
Date: PERMIT ISSUING FEE$ 10
Signature
- OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL FEE
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
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
❑ 1, 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
(Sec. 3097, Civ:C.).
ADDRESS
Lender's Name
Y
Lender's Address CITTEL.
C.
I certify that I have read this application and state that the LICENSE NO.,/� z�p �,[� CLASS
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
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date