HomeMy Public PortalAbout10409 OLIVE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR P E RM I T
I hereby,Offi tim that I have a certificate of consent to self
insurd', or a certificate of Workers' Compensation Insurance, BEATING . VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9/88
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 e d
do rhA
de artment. ADDRESS MCC?Q 001JE
(PRINT OR TYPE ONLY)
Dare 3 � Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 1
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT No. PROCESS
$b
the permit is for one hundred dollars($100)or less.) n/
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM (jJ(
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 NSPECi 'S SIGNATURE
Date Applicant COMPRESSOR, BTU fjo ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ,� 3�/ Z ��i —-
71
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 deem-
ed revoked. FURNACE: FAU GRAVITY y�
LICENSED CONTRACTORS DECLARATION FLOOR BTU O 0
1 hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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.
>_License Number
qLic. Class v' Opp, 11.)l� O
Contractor '�`�1 J° Date -�� I u
®e
❑ I am exempt under Sec. 0
Plan check fee
B.BP.C, for this reason ^ H
Date: PERMIT ISSUING FEE $ 0
Signature
TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License N1111'.Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCT.v
the structure is not intended or offered for sale(Section CITY TEL. NO. 331 ? 37.01)
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting 1 DIMS
MS
with licensed contractors to construct the project (Sec- MAIL O l t-f V t--
1)��" TOTAL �, m)��
tion 7044, Business and Professions Code). ADDRESS f
CONSTRUCTION LENDING AGENCY CITY 'rte TEL. NO _� �� CHECK 3f°0[1
I hereby affirm that there is a construction lending agency for , H�HtTE °I iQ
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). ^ /' i fr,
ADDRESS OC On-0 ,l'0001 4�16 7 )
Lender's Name a
Lender's Address CITY L TEL. NO. �f'r a j$ IJ ii 1 1 FTM 10:48
TATE I certify that I have read this application and state that the LICENSE NO. oacp p9'1' CLIC
LASS cav
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
upon ove-mentioned property for insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date