HomeMy Public PortalAbout10521 OLIVE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR, PERMIT
I' hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, I HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C '
Policy No. Company x-0046 DPW 9/88
Certified copy is hereby furnished. ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- BUILDING / ` r
tion department. FOR APPLICANT TO FILL IN ADDRESS / �, / y ✓�
(PRINT OR TYPE ONLY)
Date -Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.�'�,.••-' crv�
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO, PROCESSED BY
AIR HANDLING UNIT,CFM
the permit is for one hundred dollars($100) or less.) .;+
I certify that in the performance of the work for which this I BTU
,BOILER 'r f
permit is issued, I shall not employ any person in any manner `
'so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Dd A litant. �s1rfili'1'%p f ( I COMPRESSOR, BTU �'l I;N `'J ROUGH
NOTICE TO APPLICANT% If, after making this Certificate of � VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V lldkll!?�/WIVV OW
with comply with such provisions or this permit shall be deem-
ed revoked. / FURNACE: FAU
LICENSED CONTRACTORS DECLARATION / FLOOR BTUU ' �'�— t•; `•
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 force and effect. M }. •yam", /fit r)
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License Numb ef � �� Lic. Class : y , O
'Contractors[-+ r!• / ► f'�Dater-, ---��'" �� d
❑ I am exempt under Sec. y-
B.&P.C. for this reason Plan check fee ee
Date. PERMIT ISSUING FEE $ (i{J
Signature NA
TOTAL FEE f
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT b
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):
❑ I, as owner of the property, or my employees with ADDRESS a
wages as their sole compensation,will do the work and _ V
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER -
❑ I, as owner of the property, am exclusively contracting ''��'�'=- '% '"t t'`u '„%I1•w
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS i t.t i tom'„ % U•..s M 1.l
CONSTRUCTION LENDING AGENCY CITY TEL. NO. L
I hereby affirm that there is a construction lending agency for Y
the performance of the work for which this permit is issued CONTRACTO
(Sec. 3097, Civ. C.).
ADDRESS L : °/ � """" Wil/
Lender's Name `'1 lz. rrG' z"'
Lender's Address hfj
I certify that I have read this application and state that the
STATE
�� �,t / CLASS �/ Y
above information is correct. I agree to comply with all County ` "' G r -
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
up�n 'e �V- nt'oned prop rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date I @