HomeMy Public PortalAbout10226 OLIVE ST_Mechanical__ WORKERS' I have a cera DECLARATION APPLICATION FOR 'PERMIT
I• I hereby affirm that I have a certificate of consent to self
,"'Insure, ona certificate of,Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lob. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is-filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
19
tion department. (PRINT OR TYPE ONLY) ADDRESS /" R
Date Applicant LOCALITY•
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFMc
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner
so as to b come subject to the Workers'Compensation LLa�w/�s." BOILER,BTU /) APPROVALS DATE INS CTOR'S SIGNATURE
Date pplicci " 1 t;�vv COMPRESSOR,,BTU -60D OV ROUGH S.
NOTIC TO P LICANT: If, after making this reirt0fodfate of VENTILATION SYSTEM FINAL
Exemption, you should'become subject to the Workers'
-Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUR I7Y O/�
LICENSED CONTRACTORS DECLARATION FLOOR. TUF ((//
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and
effect.
License Numb,3ZO 7 CLic. Class / o U
09
Contract AJ-VA Date 6hilYb
❑ I am exempt,under Ac. V
Plan check fee IIL
L
B.&P.C. for this reason' - H
Date: PERMIT ISSUING FEE$
Signature TOTAL FEE ()
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 N 4$,(a 7
Professions Code): � _ figL� / #•0 0 0 0_ o
❑ I, as owner of the property, or my employees with ADDRESS&36
wages as their sole compensation,will do the work and ,Y77/S� )'° ° 3 Q 5 0
thestructure is not intended or offered for sale(Section CITY + TEL. NO. '7"®
7044, Business and Professions Code). OWNER' 0 0 a 3 Q 5 05
❑ I, as owner of the property,am exclusively contracting MAIL 6 2 3 t`8 6
with licensed contractors to construct the project,(Sec- ADDRESS
oV
tion 70Business and Professions Code).
CO �CJ
CONSTRUCTION LENDING AGENCY CI TEL. NO. '
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTO AJ~(Sec. 3097, Civ. C.). D11111.
ADDRES6�15,
Lender's Name
Lender's Address CITY TEL. N ,
STATE c=5 �¢ LIC. 0 7j}
I certify that I have read this.application and state that the LICENSE.NO. VV (, CLASS L�OcV
above information is correct. I agree to comply with all County '
ordinances and State laws relating to building construction,
and hefeby authorize representatives of this County to enter
up n the above- ntioned property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
J
Signature of Applicant or Agent ate