HomeMy Public PortalAbout5634 MCCULLOCH AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
I hereby,aff'rrm that i have a certificate of consent to self
'*ns&d, d—r a certificate of•Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
'or a certified copy thereof(Sec. 3800, Lob. 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. (PRINT OR TYPE ONLY) ADDRE S
Dat Applica� ��� LOCALITY
�z' 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($100.)or less.) �j
AIR HANDLING UNIT,CFM'
I certify that in the performance of the work for which this'
permit is issued, I shall not employ any person in any manner (f
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE I� ECTOR'S SIGNATURE
Date Applicant
COMPRESSOR,BTU Q ROUGH � ) I
�" _ ��(�•'�
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA IDA ON
with .comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
1 hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT`(commencing with Seciion 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Numbs�J Z��Z Lic. Class :� , U
ad
Date 7'-/'d7 O
E] _c t--'
I am exempt un er Sec. # 9L
Plan check fee W
B.BP.C. for this reason PERMIT ISSUING FEE$
Io03a50
Date: TOTAL FEE o 0 0 3 a 5 0 v
Signature `
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 7'0 9`$
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):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
❑ I, 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 CONTRACTO ,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
50 Lender's AddressCIT TEL. N--•-��••O�s
STATE LIC.
I certify that I have read this application and state that the LICENSE N CLASS ef 2-0
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 th ve-mentioned property for inspectiioon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ —t��
Signature of Applicant or Agent Date