HomeMy Public PortalAbout9144 OLEMA ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 200048 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN .
78A384C
I hereby-affirm that I have a certificate of consent to self Insure,
or a certificafe'Of Worker's Compensation Insurance, or a certified HEATING,-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. d" •ZCompany-5-r4rE F4cAJA COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified co is filed with the county building inspection FOR APPLICANT TO FILL IN. BUILDING
PY tY 9 P QLj
department. (PRINT OR TYPE ONLY) ADDRESS G/yJ
,
bate +/ -Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
` CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be.completed if the work Involved by the MAPIBOOK •PAGE PARCEL
permit is for one hundred dollars($100)'or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that tri the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU '
become subject to the Workers'Compensation Laws. 01Q
COMPRESSOR,BTU 6 K
APPROVALS DATE INSPECTOR'SSIDNATURE
Date APPIICBrt VENTILATION SYSTEM ,
r
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become-subject to the Workers'Compensation EVAPORATIVE COOLER '
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �,
LICENSED CONTRACTORS DECLARATION FLOOR BTU O VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
.(commencing
USPENDED UNIT,(commencing with Section 7000)of Division.3 of the Business and HEATER: WALL
Professions Code,and my license Is In full force and effect.
nJGE?S 7''DU-J LE`T`S �
- �
License Number � �� LID.Class e �o
Contractor. U J D eA11 AJ111.K Date 3"3 Z"/15 ► a
❑ . 1 am•exempt under Sec. Plan check fee U
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B.&P.C.for this reason PERMIT ISSUING FEE$ b OC
Date: TOTAL FEE U
Ii
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Cr
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions t+
Code): ADDRESS ACCT T.g
I, as owner of the property, or my employees with wages ��y 1
As their sole compensation, will do the work and the CITY TEL.NO. 33703. 106.65
structure is not intended of offered for sale(Section 7044,
Business and Professions Code). OWNER ITEM
❑
I, as owner of the property, am exclusively contracting TOTAL
-g I MAIL - .. ... I rJTttL 3.06®65
with licensed,contractors to construct the project (Sec- ADDRESS tt
tion 7044,Business and Professions Code). _ CHECK 106.65
CONSTRUCTION LENDING AGENCY CITY -T�/'/` ,, e j TEL.NO. uH�1h(�E .QO
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
I performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS .12-9 Jg , G/ENQ,y L E .
' � 0000-000�' S/20l9`�7
Lender's Name
CITY Aj D d®PA TEL.No. off, _ 9850 1 AM 8:55
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. ,�G Q CLASS —
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
prope ty for Inspectio ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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ATU F APPLICANT OR&ENTDATE