HomeMy Public PortalAbout10209 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0048 DPW 9189 n n
1 hereby af.fire that I have a certificate of consent to self insure, 7BA364C APPLICATION FOR PERMIT �J�v;i El � D �u�
ora�ertiCher i f(e c.Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
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 count building inspection FOR APPLICANT TO FILL IN BUILDING �O� J�
Y 9 P ADDRESS
department. � (PRINT OR TYPE ONLY)
Dat ,73— 9S LOCALITY
7
Applicant • NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ���oO /O O
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATOR
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY // 01
LICENSED CONTRACTORS DECLARATION / FLOOR BTU M GSD VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numb /Y / 74 Lie.Class G op s
Cant ra4 r66' Date �� ! , C
F1I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ O� F
Date: TOTAL FEE
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION -�-
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions
•rr.'-r •�
Code): ADDRESS +•'!tt:. I ~_E,L � .e
1, as owner of the property, or my employees with wages w,•—-.y
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, tire+=17
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). ,�,�/�f �y
CONSTRUCTION LENDING AGENCY CI TEL.N 7/ j:;0; + if °
.sls + .
I hereby 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
TEL.N10,7 f
Lender's AddressSTATE /L�/ G� LIC. i^ �o
I certify that I have read this application and state that the above LICENSE N T �j ! CLASS 41
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
propert fo, ins ctiourpogs. SEE REVERSE FOR EXPLANATORY LANGUAGE
Z-2-3; ^F
—SIGNATUREOF APPLICANT OR AGENT DATE