HomeMy Public PortalAbout5636 MCCULLOCH AVE_Mechanical__ R ;WORKERS'COMPENSATION-bECLARATION APPLICATION FOR PERMIT
I herebi/ affirm thg1t I have a certificate of consent to self
., insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76MeAC
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 �v
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: a PROCESSED BY
the permit Is for one hundred dollars($100)or less.).
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ` Sc
permit is issued,I.shall not employ any person in any manner
so'as To become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE I j5 R'S SIGNATURE
C
Dapplia / COMPRESSOR, BTU-396 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 19
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G AVITY
LICENSED CONTRACTORS DECLARATION FLOOR B
I hereby affirm that tam licensed under provisions of Chapter•9 HEATER- SUSPENDED UNIT
'(commencing with Section 7000) of'Division 3 of the Business - WALL
and Professions Code,and m license is in full force and effect.
y ! 27434AIL
License NumbA f �/2 L•ie. Class z , ®® 47
c o o6JV
Con Dateo 0 0305050
❑ I am exempt uncier Sec. 0-7.09-87
Plan check fee IL
IL
B.&P.C. for this reason' 4n
PERMIT-ISSUING FEE$
Date.
Signature. TOTAL FEE
OWNER-BUILDER DECLARATION 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):
E:] 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
7. 4, Business and Professions Code). •
OWNER
❑ I,as 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 CONTRACT G
(Sec. 3097, Civ. C'.).
ADDRESS V D
Lender's Namemette
CITY. TEL. O�
Lender's Address
S LIC.
I certify that I have read this application and state that the LICENSE Z �j �Z CLAS 2 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
upon t above-- ention@d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�-9-Ir7
ignature of Applicant or Agent Dote