HomeMy Public PortalAbout9507 OLEMA ST_Mechanical__ WORKER'S COMPENSATION of consent to 76A3 8DPW 9189 APPLICATION FOR PERMIT LIAAE GREEN
70-OM
I hereby affirm that'l#gave 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.) rr
Policy No. Company COUNTY COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. �y-�►
Certified copy is filed with the ounty building inspection FOR APPLICANT TO FILL IN BUILDING SS
department. n(�! (PRINT OR TYPE ONLY)
Date 3✓z—14 Applica' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKER NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work Involved by the ASSESSOR
ermit is for one hundred dollars $100 or less. MAP BOOK�rpZ PAGE O�� PARCELQ
p ( ) ) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED
I certify that in 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. 1 Q �v
` COMPRESSOR,BTU V i"^'�
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 �.�. Iva
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV TY VAI ON /
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 and HEATER: WALL
Professions Code,
land
)myy license is In full force and effect.
License Number �-�"� Lic.Class
Contractorf'"`l(�-�[^-Y ` f� Date 1 °g
❑ Plan check fee f'
I am exempt under Sec. TE _ C
ISSUING FEE
PERMIT SS $ 13
` ' '
B.&P.C.for this reason
7Q
Date: TOTAL FEE �E eiL :r7�'7 u7 U
1]�'
5f1'7�•�.IS ^�c
Signature PLAN CHECK APPLICANT a
OWNER-BUILDER DECLARATION : ll'it N-K °1_! s
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS r 0101_1_s-*-1' 3 "•
I, as owner of the property, or my employees with wages _
as their sale compensation, will do the work and theCITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER 6- (��S
❑ I, as owner of the property, am exclusively contracting MAIL ® A
with licensed contractors to construct the project (Sec- ADDRESS T�
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY r c TEL.NO. L-�1.Uo-2 1,
I hereby affirm that there is a construction lending agency for CONTRACTOR �t ,
the performance of the work for which this permit s IssuedALOWAO rt). 6mmp- G-0
(Sec.3097,Civ.C.).
ADDRESS 554 3
Lender's Name
CITY A TEL.NO. 7 Q�
Lender's Address 1 �-f
I certify that I have read this application and state that the above STATE NO.22� C ASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
t-r-RP4,sentatives of this County to enter upon the above-mentioned
pro arty for Inspect' urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG ATURE OF APPLICANTJORNDATE
75Aaa'dc Zi
CE Aa 181REV.6/781®s APPLICATION FOR P
HEATING = VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILEYING
(PRINT OR TYPE ONLY) ADDRESS
LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
• CROSS ST. G/
ABSORPTION UNIT,BTU �
OWNER
AIR HANDLING UNIT,CFM MAIL
ADDRESS
BOILER,BTU CITY TEL.NO:
COMPRESSOR,BTU CONTRACTOR
VENTILATION SYSTEM
. ADDRE5571 yrs'�GjdGJ'(� C�✓�y/y ��"'
EVAPORATIVE COOLER CITY `C.�� TEL.NO.
.7,F 77
FURNACE: FAU GRAVITY STATE p�f��Q" LIC.
FLOOR BTU LICENSE NO. / 7 CLASS .00
HEATER: SUSPENDED UNIT APPROVALS DATE INSPECTOR'S SIGNATURE
WALL
/ ROUGH.
(� FINAL7 �,
0 e5
INSPECTION RECORD u
99
Plan check fee 25% of above.
PERMIT ISSUING'FEE$.
TOTAL FEE
PLAN CHECK APPLICANT . PLAN CHECK VALIDATION
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT'I HAVE READ THIS APPLICATION AND
STATEALL
O DINANC STHE ANDBOVE LAWS REGULATINGTHAT IS CORRECTD EATING VENTILAT NAGREE TO COMLYIGH AIR 1 12 2 19.3 A
CONDITIONING. PERMIT VALIDATION ## a o 0 0 4 1
I HEREBY CERTIFY THAT I AM NOT ACTING IN'VIOLATION OF
CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL CODE 3,00 OF THE STATE OF CALIF I . 2-o 0 1 3,0 0
SIGNATURE
OF PERMITTEE a r�'�"� / i i S
o.o 0 1 3,000
DISTRICT NO. - PR SED BY _ ,
o � � , - 0.1,•1 2--79