HomeMy Public PortalAbout10124 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CE°'Ss BC(2-80) A P D L IC A T 1®11 FOR P E lid M PT 7'
I hereby affirm that I have 1•c@rtNfiJste of consent to self N-`S U'`C tl�7'U f�
insure, certificate Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIOPNING '1
a certified
c (
d copy thereof(Sec.3800,Lab.C.) U
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANG LES f NG ARID SAFETY
❑ Certified copy is filed with the county building inspection UI LDING
department. FOR APPLICANT TO FILL IN ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST �Q f� � � a
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. .� /
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P Es By U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
L7 C�
permit is issued, I shall not employ any person in any manner. I=O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU 0
Date Applicant. 1 APPROVALS DATE INSPECTOR' SIGNATURE W
COMPRESSOR,BTU v 'U ROUGH .. D'
t!1
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 2
Exemption, you should become subject to the Workers' FINAL _
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. •
FURNACE: FAU GR VITY r�
LICENSED CONTRACTORS DECLARATION FLOOR: BTU Q
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED WIT
9 (commencing with Section 7000)of Division 3 of the Busi• WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busy-
ness nd Professions Code): -ADDRESS
v I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO.
7044, Business and Professions Code). J •
❑ OWNER
I, as owner of the property, am exclusively contracting +
with licensed contractors to construct the project MAIL 2.9
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY' /.y ��, TEL.NO.
I hereby affirm that there is a construction lending agency 2 0 - 27 0 0
for the performance of the work for which this permit is CONTRACT R
issued CSec.3097,Civ.C.). I
0 2 ti
Lender s Name ADDRESS Q 0 0
Lender's Address CITY U TEL.NO. 0—t?
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws reg lating Heating, Ventilating and
Air Conditioning,a d hereb authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Count t nt r upon t e above=mentioned property for
insp r s
-
Signature of Permittee Date