HomeMy Public PortalAbout10508-10512 OLIVE ST_Mechanical__ ION
. ,WORKER'have aENSATate of consent to 20-0046 364C PW9/89 APPLICATION FOR PERMIT LANE GREEN
I heretby.affirm that I have a certificate of consent to self insure,
or a certificate of worker' Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Stec.3800 L. C.)
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Policy'No. Company 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 BU
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department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY a ✓/ 'j"
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the MAPESSOR BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any perso n any manner so as to BOILER,BTU
become sub ect to th Workers'Com en 1 Laws.
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COMPRESSOR,
t'.G y.l°eJ
COMPRESSOR,BTU J
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applica ' ' VENTILATION SYSTEM
NOTICE OAF} LIC NT: If, aft aking this Certifica a of ROUGH
Exemptio ,you should become su ct to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL Z
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. _
��' License NumbLicClass
er . A/t Poo-
1 _y `
1,�`I� T C•-
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Contract Date I r�^#=.-(__ C
r_1 I exempt under Sec. Plan Check fee -y_L AL o :L5 a
B.BP.C.for this reason PERMIT ISSUING FEE$ / :�i a
Ute' O � C
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Date: TOTAL FEE
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Signature a
PLAN CHECK APPLICANT U.
OWNER-BUILDER DECLARATION �^ --
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions �` e A�- ® tri-lo+}z
Code): ADDRESS
F1 1. as owner of the property, or my employees with wages 1
as their sole compensation, will do the work and the CITY
P TEL.NO jv
3 S��
structure is not intended or offered for sale (Section 7044, 14 0, ef
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 07
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS (9
Lender's Name
CITY TEL.NO
leelA–
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LLICENSE NO. f 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-menti ed
property IF i pact' purfiro%es. SEE REVERSE FOR EXPLANATORY LANGUAGE
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NA F APP I' OR E DATE