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Home My Public Portal About9479 OLEMA ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy No.—Company Company E/ 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 r_1 G tion department. ADDRESS CIL/ 7 (PRINT OR TYPE ONLY) Date Applicant LOCALITY—r—c—_--Vl. I oz- G-) 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($100)or less.) AIR HANDLING UNIT,CFM © 7�# I certify,that in the performance of the work for which this _ permit is issued, I shall not employ any person in any manner 7 somas to become subject to the W rkers'Compensation jaw/s. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE COMPRESSOR, BTU ROUGH Date r�_ plicant NOTICE TO APPLICANT! If, after king this Certificate of VENTILATION SYSTEM FINAL 'd�., Exemption, you should Lr to the Workers' Compensation provisions of the La or Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 A HEATER: SUSPENDED UNIT_ (commencing with Section 7000)of Division 3 of the Business Ij WALL C/U 10 and Professions Code,and my license is in full force and effect. O License Number Lic. Class ® t p t5 Contractor Date ❑ 1 am exempt under Sec. V Plan check fee ®- B.&P.C. for this reason Date: PERMIT ISSUING FEE$ 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 Dew Miy_rLASya N11111. Professions Code): El1, 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 - c TEL. NO. P_ qq 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 CONTRACTOR Qwp4ip (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address that I have read this application and state that the STATE LIC. I cerfif y pp LICENSE NO. CLASS 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 u o the above-mentioned�proporyfar inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Applicant or Agent Date