HomeMy Public PortalAbout10539 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm th6I 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.)
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 BUILDIADDRESS
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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($700)or less.) — f
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU y
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU jp.��
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER p `
provisions of the Labor Code,you must forthwith comply with such FINAL 6
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVI
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
1-4-4
License Number Lic.Class "/• ��
0.
Contractor Date C
ElI am exempt under Sec. Plan check fee a
D
B.&P.C.for this reason
PERMIT ISSUING FEE$ C
Date: TOTAL FEE U.
Signature a
PLAN CHECK APPLICANT U
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME ®
code):
_
for the following reason(Section 7031.5, Business and Professions
e) ADDRESS
I, as owner of the property, or my employees with wages `
:�Le
= I,. 7.
as their sole compensation, will do the work and the CITY TEL.NO. -- s L-r=y.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). WOWNER
❑ I, as owner of the property, am exclusively contracting MAIL :.)',r;i_ '�� m 15
c
with licensed contractors to construct the project (Sec- ADDRESS /0.�& j-eJ ':�I�,"•(; .`t
tion 7044,Business and Professions Code).
CITY TEL.
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 �J000.
(Sec.3097,Civ.C.). r f41;
ADDRESS I
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree t0 comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represents Ives of this County to enter upon the above-menti ned
proper r inspection rposes.� SEE REVERSE FOR EXPLANATORY LANGUAGE
SI AT OF ICAN GE T DAT