HomeMy Public PortalAbout5634 1/2 MCCULLOCH AVE_Mechanical__ `o rs WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I ,have a certificate of.consent to self
'insure, or a cbrtificate of'Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
"or a certified 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 5 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.
(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.) AIR HANDLING UNIT,CFM
I certify that in the performance of the'work for which this \J • ��
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 ^ INS TOR'S SIGN
#TURE
Dot;- 7
�� App'lic int COMPRESSOR, BTU �I�p ROUGHOd
NOTICE TO APPLICANT: if, a er making This tertificate of VENTILATION SYSTEM FINAL /i— -
Exemption, you should'become subject to the- Workers' '
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU' VIT
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of-Chapter 9 SUSPENDED 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.,2�2b Zic. Class G Z o ► U
G Dates'-9- 7
❑ lam exempt uncle ec. gig
Plan checkfee to
B.&P.C. for this reason' PERMIT ISSUING FEE$ 0 0
Date:.
Signature TOTAL FEE a a a 3 a 5 0 c_i
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 07.09-87
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
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code)..
- OWNEKLr
❑ Las owner of the property, am exclusively contracting
with licensed contractors to construct the,project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
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 I CONTRACT
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
ITY
Lender's Address
X326 /
• I certify that I have read this application and state that the LICENSE N CLASS ZO
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 t e bove- entioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date .