HomeMy Public PortalAbout10406 OLIVE ST_Mechanical__ A,NORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
-1 hereby affirm that I have a certificate of consent to self
insure, ora certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
r fied copy thereof (Sec. 3800, Lab. C. 76A364C
CE-818(REV. 10/81)
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
N�,� tion department. ADDRESS10# i
4D e ' Applicant /J� I (PRINT OR TYPE ONLY) LOCALITY I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE v
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. 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 p
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 4 QOc7 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisipns of the Labor Code, you must forth- EVAPORATIVE COOLER V L AT O
with comply with such provisions or this permit shall be
deemed revoked. I FURNACE: FAU BTU GRQAVITY
LICENSED CONTRACTORS DECLARATION i
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 f yce d eff
�" !� 7 0
License Number l Lie. ass , t)
1A fi Ai Milk Im
Contractor e
❑ I am exemp under Sec.
Plan check fee
BAP.C. for this reason Date: �
PERMIT ISSUING FEE$
TOTAL
OTAL 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 NAME
Professions Code): �og �7,4]i1
F-1 1,I, as owner of the property, or my employees with C
wages as their sole compensation,will do the work and EMS
the structure is not intended or offered for sale Section CITY TELNO. T,fTOTAL 3
7044, Business and Professions Code).
OWNER is
Els 7?u flt(
I, as owner of the property,am exclusively contracting HECK
with licensed contractors to construct the project (Sec- MAIL
ADDRESS (j S (=j �] �1j
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITYTEL. NO.,N4"
1 hereby affirm that there is a construction lending agency for r-n
the performance of the work for which this permit is issued CONTRACTOR , CICIGO_I(_oI Ct"tZ-11.4
1
(Sec. 3097, Civ. C.). i �,y r�
ADDRESS '3'-13 1 AM 7 s 16
Lender's Name
CITY TEL. NO.
Lender's Address STATEf r CLASS
I certify that I have read this application and state that the LICENSE NO.
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authori representatives of this County to enter
u n the above-m tioned property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dole