HomeMy Public PortalAbout10411 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW9/89- APPLICATION FOR PERMIT L�,P,,nE
76A3
I hereby affirm-that I have a certificate of consent to self insure, 76A364C
Or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) (J
Policy No'25/ G Company KPy�LIy COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS I C7 ( � c:51-1
department. (PRINT OR TYPE ONLY)
LOCALITY
Date l r V Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. 1.4 ISL G
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by the
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER BTU �.Q
become subject to the Workers'Compensation Laws. 'Tc �(o �"
COMPRESSOR,BTU ��-�o O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER e
provisions of the Labor Code,you must forthwith comply with such FINAL f 7
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 2.& 00 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. q A-0
License Number 2- Lic.Class
Contractor —F#<9 Date t Z,—3L— C
❑ I am exempt under Sec. Plan Check fee V
cc
BAP.C.for this reason PERMIT ISSUING FEE$ ZI 30 C
Date: TOTAL FEE 51
LL
Signature n'
PLAN CHECK APPLICANT tl
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Coe): ADDRESS ACCT o 4
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 33303 88090
structure is not intended or offered for sale(Section 7044, 1 ITEMS
Business and Professions Code). OWNER U?2t PJ cS rOr 2
❑
MAIL TOTAL
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS O L l vL/✓G'� 5/ �vo
tion 7044,Business and Professions Code). CITY CHECK 0
CONSTRUCTION LENDING AGENCY /�� 90
i>'{/Jlr�� Gti TEL.NO.s fi .�_(��g CHCHANGEC n
I hereby affirm that there is a construction lending agency for ► X00
performance of the work for which this permit is issued CONTRACTOR L _-FP-
the
(Sec.3097,Civ.C.).
/�' ' � ADDRESS �� 5 U S y�C r /a�� 0000-0001 1/30/96
Lender's Name ,tVy �7
CITY /;�J, TEL.NO.2,fq �3 L/ 4554 1 AM 9:36
Lender's Address STATE LIC. / 2O
I certify that I have read this application and state that the above LICENSE NO. '�'��22 CLASS
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 the above-mentioned
proper"r foTT spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUR OF APPLICANT OR AGENT DATE