HomeMy Public PortalAbout10425 OLIVE ST_Mechanical__ 046
WORKER'S COMPENSATION
certificate
of consent to 1766AA364C PW 9/89 APPLICATION FOR PERMIT LIME GREEN.
I hereby affitm that I have a certificate o}consent to self Insure,
or a 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. r
❑ Certified copy is filed with the county building inspection FOR APPLICANT o0 SILL IN ADDRESS f Z�DING /
department.
Date ApplicantLOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOKS PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ii
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person In any manner so as to BOILER,BTU j-
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become subject to the Workers'Compensation Laws.
t F COMPRESSOR,BTU �Dr O� d
Date f�`'ZI'y Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after making this C rtificbte of ROUGH Le)_ -�
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. f FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU O VALIDATION 110/
I hereby affirm that I am licensed under provisions of Chapter g HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is In full force and effect.
AC
License Number 73 L( Lic.Class C -317 TT °41)
I ® i=
Contra Date -' r
❑ I TAL 33 a _P0 C
I am exempt and r Sec. Plan.Check fee C`—HECK J6°y'I
r Q
BAP.C.for this reason PERMIT ISSUING FEE$ 14p _ C
Nu a kjlj
Date: TOTAL FEE U
O
Signature PLAN CHECK APPLICANT [ILI[lr!- IL�I; �;(,f '= co
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME , !smoi r y AM 9-'27
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting , MAIL Z c�-
with licensed contractors to construct the project (Sec- ADDRESS y/
rofessions Code).
tion 7044,CONSTRUCTIONPLENDING AGENCY
CITY, TEL.NO11�J6 7J
I hereby affirm that there is a construction lending agency for CONTRA W
the performance of the work for which this permit Is Issued,
w
(Sec.3087,Civ.C.).
ADDRESS ?
Lender's Name
CITY& dTEL.NO. (0
Lender's Address 2
I certify that I have read this application and state that the above LICENSE NO.3�?6-d LIC.
d_-
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 '
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT V DATE