HomeMy Public PortalAbout9454 OLEMA ST_Mechanical__ Y
WORKER'S I have
a certiIONficate
of consent to 2D-OD4aDPW 9la9 APPLICATION FOR PERMIT LIME GREEN
7fSA364C
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) "d
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy Is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY) DING
D/
Date Applicant LOCALITY / c l j L7
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 MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit y
is issued, I shall not employ any person in any manner so as to BOILER,BTU ��✓
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUAV�tTY _ �.
LICENSED CONTRACTORS DECLARATION FLOOR TU d J VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is In full force and effect.
License Number 7 �5 Lic.Class ✓�2U rir-1-� ■F
Contractor 49Crate T
❑ `I M"
I am exempt under Sec. Plan check fee D
TOT
1•: I
B.&P.C.for this reason PERMIT ISSUING FEE$ 61/0 I ` ` �, IC-
1-7 Date: Of TOTAL FEE (`s-I '_� ?)1 Lct
Signature ,,.' .L O L•tfANGE °�t- U
WNER-BUILDER DECLA TION PLAN CHECK APPLICANT G
hereby affi at I am exempt from the ontractor's License Law NAME
for the folio ng reason (Section 7031.5, Business and Professions ���/ i_I_(_!-li:!i� _ 1i]{9%!
Code): "rC• P • ''t•■'�'
❑ ADDRESS j d o�r'?A I:� 1 Art iS l■t:
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY �� TEL.NO.
structure is not intended or offered for sale (Section 7044,
ZYb
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).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for ONTRACTOR 1>
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS �d b
Lender's Name
CITY TEL.NODS j3_ 6
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. �i:3 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
property or inspection p s s. SEE REVERSE FOR EXPLANATORY LANGUAGE
NATURE OF APPLICAN R AGENT r e DATE