HomeMy Public PortalAbout10101 OLIVE ST_Mechanical__ 'WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PRMrT LAME GREEN
q. 76A384C
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
ccooppy[thereof(Sec.3800 Lab.C.)
PPOIIcY/No;`� //�wampa �y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
L+T Certified copy is hereby furnished. f—/—
Certified copy is filed with the county buildin Inspection FOR APPLICANT TO FILL IN BUILDINGADDRESS
department. ,pA f� ` �J��yr p�Ar/UQ5 (PRINT OR TYPE ONLY)
Date dk MApcplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �G
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU CJ
APPROVALS DATE INSPECTOR' IONATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU Q VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license Is in full force and effect. /Q
License Number 7156�3 Lic.Class J-;'" ACCUL
L
® 3303 91030
Contractc��' "�Da�fe 6 c
Plan check fee 1 ITEMS
❑ I am exempt under Sec. TOTAL 91. 30 C
BAP.C.for this reason PERMIT ISSUING FEE$ �50 EHEC:{: F
91030 c
Date: TOTAL FEE Q Lt
SCHANGE .00
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
d
1 hereby affirm that I am exempt from the Contractor's License Law NAME , 0000-0001 6/26/96
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS 0 I o d 18, b� 7129 1 AIM e 25
F1 1. as owner of the property, or my employees with wages Y
as their sole compensation, will do the work and the CITY TEL.NO. /0
structure is not intended or offered for sale Section 7044, (,
Business and Professions Code). OWNER �L
❑ 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).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY I
I hereby affirm that there is a construction lending agency for CONTRACTOL!��- W/,Z� e�e
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). r
ADDRESS o�7
Lender's Name
C TEL.N ? �a Y-0.0
Lender's Address STATE / p LIC. �I
I certify that I have read this application and state that the above LICENSE NO. 71r l0 U3 CLASS �/cr
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 for insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'SIGMATURE OF APP CANTO AGENT
DATE