HomeMy Public PortalAbout10158 OLIVE ST_Mechanical__ ' W�RKER'S COMPENSATION DECLARATION 20-0046 DPW
PW 9/89 APPLICATION FOR PERMIT , I
1 hereby affirm
that have a certificate of consent to self Insure, �.� ll�
ora certificate iii Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING u U
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy Is filed with the county building inspection FOR APPLICANT TO FILL IN BDDRESS d s0 Q 'y2
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the MAP BOOK &PS PAGE/,?dnp� I PARCEL O/71
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. Q
COMPRESSOR,BTU APPROVALS DATE INSPECTOR'8S NATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. / FURNACE: FAU I GR9VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU (50,000
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
_. 1
License Number
LID.Class C "F17
Contractor Date 1 '`-'
F1 I am exempt under Sec. Plan check fee y'==._;j _ 1 i 0 m 1 C
B.&P.C.for this reason PERMIT ISSUING FEE$ r�: . lit' 11f F
Date: TOTAL FEE l C$IANa
Signature U
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION 00312-01C
_1 11
,r
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the followingreason Section 7031.5, Business and Professions f E�1 J. i d_`'`
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, \
Business and Professions Code). OWNER )
❑ I, as owner of the property, am exclusively contracting IL on4
with licensed contractors to construct the project (Sec- ADDRESS e
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY r TEL.NO.
1hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit is issued
(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 inspection
pua.
SEE REVERSE FOR EXPLANATORY LANGUAGE
(IM
SIN T RE DATE F AP LICANT�AGENT