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Home My Public Portal About10219 OLIVE ST_Mechanical__ r '{ A WORKERS'COMPENSATION DECLARATION �.raafirm t cFf I t ave.ti certIC'oate,or torrent to elf APPLICATION FOR PERMIT a c tified copy thereof(Sec. 3800, Lab. G.) 764C HEATING VENTILATING AIR CONDITIONING CE-818(REV. 10/81) oli Nod/(oto/ L� Company. �/aN� _9 Certified copy is hereby furnishe . COUNTY OF LOS ANGELES BUILDING AND SAFETY 'Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. p� ADDRESS d� (PRINT OR TYPE ONLY) Date — o Applicant(o G4o& X,12 VON LOCALITY �/1t L G Ct1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work involved by ABSORPTION UNIT,BTU DISTRICT NO: x,/ PROCESSED the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM �_e I certify that in the performance of the work for which this (J permit is issued,I shall not employ any person in any manner so as to become subject-to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPE TOR'S SIGNATURE Date Applicant COMPRESSOR,BTU y4.O ' o ROUGH r NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I KA "D 04 with comply with such provisions or this permit shall be deemed revoked. FURNACE:. FAU ITY a, LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT - '(commencing with Section 7000)of Division 3 of the Business - WALL and Professions Code,and my license is in full force and effect. "Of" N12 O License NumberM731 Lic. Class rego v , ► U,i Contractor4wxe Date y 30—9® ❑ I am exempt under Sec. Ul Plan check fee h B.BP.C. for this reason' � PERMIT ISSUING FEE$ Date: TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME i Professions Code): �t , ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ACCTA the structure is not intended or offered for sale(Section CITY- TELNO. 3307 49.75 7044, Business and Professions Code). OWNER Ayrs A/we ®!v 1 ITEMS El 1,as owner of the property,am exclusively contracting _ with licensed contractors to construct the project (Sec- MAIL ADDRESS �(/ TCIp�- tion 7044, Business and Professions Code). 49.75 CONSTRUCTION LENDING AGENCY 'CITYTEL. NO. d s CHECK 49.75 'I hereby affirm that there.is a construction lending agency for /� the performance of the work for which this permit is issued CONTRACTOR /1lD6Z ( �a�GC /✓t°i , CHANGE .00 (Sec. 3097, Civ. C.). ADDRESS iZO 1 Lender's Name / N , ciivr' 0000-0001 8724759 -• CITY � le 61� TEL. NO. !j 7 Lender's Address 5289 IAM10�18 I certify that I have read this application and state that the STATE LICENSE NO. Jy CLCA.S C v Q 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 Eup �e�tt1 property for ins c 1 p r�ses. SEE REVERSE FOR EXPLANATORY LANGUAGE. Signature of Applicant or Agent of Date ?TAAJMd A? .4-TAP 1-.d A-1,10- _2'1V ION a, WOthat IS have a certificate of consent to 766A364C DPW 9189 APPLICATION FOR PERMIT LIME GREEN; I here6yatfjfm that I have a certificate of consent to self insure, ora certificate of 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 county buildinginspection FOR APPLICANT TO FILL IN BUILDING C department. p (PRINT OR TYPE ONLY) ADDRESS LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST f CROSS ABSORPTION UNIT,BTU ASSESSOR COMPENSATION INSURANCE OR ; - (This section need not be completed if the work Involved by the. MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSE BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any ma ner so as to BOILER.BTU become subject to the Workers'Compensa' n Lavos. *v COMPRESSOR BTU APPROVALS DATE INSPECTOR'S SIGNATURE Data pplican VENTILATION SYSTEM NOTICE TO APPLICANT: if,•after mak ng, is Certificate of ROUGH Exerhption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions,or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is In full force and effect. nn License Number Lie.Class P�t� poll. d Contractor Date CC". ❑ I am exempt under Sec. Plan Check fe a B.&P.C.for this reason PERMIT ISSUING FEE$ C Date: TOTAL FEE p J u • Signature '' PLAN CHECK APPLICANT DECLARATION IA- OWNER-BUILDER U, 1 hereby affirm that I am exempt from the Contractor's License Law NAME , for the following.reason (Section 7031.5, Business and Professions Code): 1ADDR SS ' ❑ 1, as owner of the property, or my employees with wages ACCT. Y. as their sole comperisatlori, will do the work and the CITY TEL. O. � °g c. structure is not Intended or offered for sale(Section 7044, =, j ,� 60.1• Business and Professions Code). OWNER ❑ 1, as owner of the property, am exclusively contracting 1 IIEnS with licensed contractors to construct the project (Sec- ADDRESSL ,�$® �' tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. TOTACASH CITY I hereby affirm that there is a construction lending agency for CONTRACTOR I performance of the work for which this permit Is Iss ► i::}�(h�ta °I ue (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. tfVtl — Si A 4 r/ 2/9 Lender's Address STATE LIC. 1564' 1. 9'138 1 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 8nd State l6rt* to buil 'ng con coon,end hereby authorize representas Co y t0 r upon the above-mentioned proon rpo SEE REVERSE FOR EXPLANATORY LANGUAGE NA RE OF APF NT OR AGENT DATE '