HomeMy Public PortalAbout10104 OLIVE ST_Mechanical__ ' as WORKER'S COMPENSATION DECLARATION 2MO4A384 DM 9189 APPLICATION ®�I��991d0��
N,here(�r.afifirm that�l have a certificate of consent to self insure,
or a certi)materofWorker'eCompenga;on4nsurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy'thereof(See. 800 Lab.C.) + A ' " luj
Policy,No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
BUILDING
TO FILL IN
Certified copy is filed with the county building inspection FOR AADDRESS p Q
• department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST' do, df
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the AMAP SSESSOR
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permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
PAG
DIsrRICTNOK PROCESSED
OCESSED BY PARCE
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU yo
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with such EVAPORATIVE COOLER FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU D VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license Is in full force and effect. _
o OIC
License Number LID.Class
WAIT
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Contractor Date � --,•rs'� '••"�'s "' I
❑ �' C
Plan check fee ��'`-0a' '�`'�' �'''�-'`��- �%
I am exempt under Sec. •r ,j^ Q
BAP.C.for this reason PERMIT ISSUING FEE$,L74 O& s 1 1,E C
[ 1 A 103 . 351--
Date:
TOTAL FEE S l4 .f rj�.;c LL
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE :�� C/
i hereby affirm that I am exempt from the Contractor's License Law NAME �jW4��r
for the following reason(Section 7031.5, Business and Professions c[i S&
Code): ADDRESS �pf0 LlJ-00011 31`1-6/5
I, as owner of the property, or my employees with wages ,;)
7 G — Cid X1-35 a.�F # a
as their sole compensation, will do the work and the CITY TEL.NO. a-F
structure is not intended or offered for sale (Section 7044,
i
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 4K
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending,agency for CONTRACTOR
the performance of the work for which this permit is issued �2•yy' PW
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
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 ipqlgtion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
OF APPLICANT OR AGENT DATE