HomeMy Public PortalAbout10034 OLIVE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
:,'1"hereby'af4irm that I have a certificate of consent to self
insbre;`"or a certificate of Workers' Compensation Insurance, 76A36ac HEATING - VENTILATING - AIR CONDITIONING
or o,cettified copy thereof(Sec. 3800, Lab. C.) ;:e. „y
,;'* 20-0046 DPW 9/88
P❑ol'Icy No. Company
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 /00396/1
�`
tion department. (PRINT OR TYPE ONLY) /ADDRESS 0O`j 7 ®!1 U G x7
Date Applicant LOCALITY Q'Ns)91
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 9,q•1d w ,,,
(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.)
I certify that in-the performance of the work for which thisAIR HANDLING UNIT, CFM
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 D IN ECT�R'S SIG TU E
Date Applicant COMPRESSOR, BTU 38 00 0 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VtOIDAT
withcomp with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
License Number Lic. Class , d
O
u
Contractor Date
❑ I am exempt under Seca IO
Plan check fee u
B.&P.C. for this reason H
Date:
PERMIT ISSUING FEE $ /�
TOTAL
OTAL 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
Professions Code):
dMil '06 I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. v
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). L:(. ,a
❑ '�Q�T-`!��
I, as owner of the property, am exclusively contracting Sa�� 47.00
with licensed contractors to construct the project (Sec- " MAIL �aa Y
tion 7044, Business and Professions Code). ADDRESS �ud 3 T ��1 f�P
CONSTRUCTION LENDING AGENCY ' '
CITY TEL. NO. �(�a S'63
I hereby affirm that there is a construction lending agency for TOTAL �- a 7
m 00
the performance of the work for which this permit is issued CONTRACTOR -
Lenders Name
(Sec. 3097, Civ. C.). i a ��JJ CHECK =t7■+•�'1-•
ADDRESS S*,, 43 40 e*4- CHANGE-
-
CITY TEL. NO.
Lender's Address
I certify that I have read this application and state that the } STATE LIC.
LICENSE NO. CLASS ! ! [11 —(+(+�1� �3JJt;' •;!]
above information is correct.I a ree to comply with all County -, �-+
ordinances and Stat la s re ting to building construction, x.552 1 AM 10:33
and her&Ov
ri r res tatives of this County to enter
u o thti ed operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date