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HomeMy Public PortalAbout9541 OLEMA ST_Mechanical__ WORKERS'COMPENSATION DECLARATION t APPLICATION FOR PERMIT F hejeby affirm that 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.) CE-818(REV. 10/81) ';Policy No.Xe/30 C �_3DIISrS��ompany 1"�49110(ZM 1,9 ����� 81 Y COUNTY OF LOS ANGELES BUILDING AND SAFETY ®- Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS 4s'yj/ C. OZZ00/'f 01 r Date�r6 �� ApplicantLOCALITY -Ti9eWA" C1 T'V NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTI N FR M WORKERS'4::) NEAREST COMPENSATION INSURANCE- CROSS ST. Oil 14 14&Fiii� (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($100)or less.) AIR HANDLING UNIT,CFM C� I certify that in the performance of the work for which this c permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. / BOILER, BTU APPROVALS DATE INSP R'5 SIGNATURE Date Applicant / COMPRESSOR,BTU �+j ©�� G" ROUGH �C 'J" i� t NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL L Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. 9 FURNACE: FAU _GRAVITY LICENSED CONTRACTORS DECLARATION / FLOOR BTU _M hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. O License Number 451 it 6 1 Lic. ClassC-2.0 _ Contractor All 14—�TJTc,& Date /V_—a6`&1 O ❑ I am exempt under Sec. Plan check fee a us B.BP.C. for this reason �A Date: PERMIT ISSUING FEE$ (f Signature �. TOTAL FEE OWN - UILDER DECLA ATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Can ractor's License 10. 1 Law for the following reason (Section 7031.5, Business and NAME Professions Code): N • °s El30I, as owner of the property, or my employees with ADDRESS 41�� 30.513 t)- wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sole(Section 11 EM•E' 7044, Business and Professions Code). OWNER D er+,iei TOT J 30 -50 El 1, I, as owner of the property, am exclusively contracting r t with licensed contractors to construct the project (Sec- MAILADDRESS `/ )7rry� 57-- e..{-ECK 0.55 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY r TEL. No. CHANGE °00 1 hereby affirm that there is a construction lending agency for 1 Cry "y the performance of the work for which this permit is issued CONTRACTOR ^I;Q—1 er-N 14 C i w C . Poo. (Sec. 3097, Civ. C.). �I:l;ill—fllri 1/ 6/P Lender's Name ADDRESS �"1C4 RQ 0246 1 Atli i:211 CITY C.90114 TEL. NO. y`y I;_8q q� .3 O I t!1 1 t 1 Lender's Address STATE LIC. , I certify that I have read this application and state that the LICENSE NO.-TV 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 upon above-menti7rd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 6 ;gnat of Applicant or Agent Date