HomeMy Public PortalAbout10215 OLIVE ST_Mechanical__ dell
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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a cer led copy,t ereof(Sec. 3800, b. C.) 76A364C
/�y�CE-818(REV. 10/81)
❑Icy o.__Company /v
Certified copy is hereby furnishe . COUNTY OF LOS ANGELES BUILDING AND SAFETY
D9Certified copy is filed withthe ounty buildingrin - FOR APPLICANT TO FILL IN BUILDING h
totion department. (PRINT OR TYPE ONLY) ADDRESS Q U e
AL
Date Applicant LOCALITY
rnt ;k� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
Td
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 64 j `
1reW/
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which.this �CV
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers"Compensation Laws. } BOILER,BTU //FF APPROVALS DATE INSP OR'SSIGNATD
Date Applicant [ COMPRESSOR,BTU Z V® ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �..
i
1,17
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with.comply with such provisions'or this permit shall be
deemed revoked. FURNACE: FAU VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. g
License Number 50' Li ss r+C�0 e3 0
—997 Im
Contractor JIZ Date O
❑ 1 am exempt under Sec.
Plan check fee
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.B.&P.C. for this reason'
' PERMIT ISSUING FEE$ - •-•--
Date: TOTAL FEE 4.1 2 2 6 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # 0 0 0 0 0
I hereby affirm thot,l am exempt from the Contractor's License Poll" ( o 0 3 a Q
Law for the following reason (Section 7031.5, Business and NAME o 0 0 3 Q Q
Professions Code):
❑ I, as owner of the property, or -my employees with ADDRESS ( 2 0 1 8 8
wages as their sole compensation,will do the work.and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER n f e� � �
❑ I,as owner of the property, am exclusively contracting
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with licensed contractors to construct the project (Sec- DDLR ESS Q rrf
tion 7044, Business and Profession's Code).
CONSTRUCTION LENDING AGENCY CITY /� CE� TEL. NO. Cl3
I hereby affirm that there is a construction lending agency for vv
the performance of the work for which this permit is issued CONTRACTOR J �/� C�r,N� /��
(Sec. 3097,Civ. C.). A.
ADDRESS / NNCr�j —
Lender's Name
CITY 7LOA I° eyr TEL. NO.�
Lender's Address STATE -- LIC.
I certify that I have read this application and state that the LICENSE NO.'4/03[ CLASS to
above 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
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,the ove-mention perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of'Applicant or Agent �� D;P Q