HomeMy Public PortalAbout10557 OLIVE ST_Mechanical__ 4 WORKER'S COMPENSATION
ate of consent to 20.004uDPW 9/89 APPLICATION FOR PERMIT LIME GREEN
I heraby affirm that*1 have a certificate of consent to self Insure, 76A364C
or a cbrtificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy -��Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Nr I Certified copy is hereby furnished.
❑ Certified copy is filed with the unty building' s n FOR APPLICANT TO FILL IN BUILDING
Ij
department. (PRINT OR TYPE ONLY)
Date `� A Icant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE O EXEMPTI N F M WV PIKERS' CROSS ST.
COMP NSATION I SU�AN E ABSORPTION UNIT,BTU
SSOR—
(This section need not b complete if the work involved by the MAP EBOOK PAGE PARCEL
permit is for one hundred Here 00)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
1 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 toBOILER,BTU
become subject to the Workers'Compensation Laws. ad
COMPRESSOR.BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of L ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL '3"v Z
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 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'm1 y license is in full force and effect. 70
r&License NumbeL 1 L h Lic.Class M_
�ContracTof Date — , C
❑ I am exempt under SIC. Plan check fee a
B.&P.C.for this reason PERMIT ISSUING FEE$ H
Date: TOTAL FEE p� .a V
Signature – j 'li 13
PLAN CHECK APPLICANT ,s
OWNER-BUILDER DECLARATION r•r--:' s
I hereby affirm that I am exempt from the Contractor's License Law NAME 001.for the following reason (Section 7031.5, Business and Professions -1_I AL .er.� p
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages Z 0 'E "�
as their sole compensation, will do the work and the CITY TEL.NO,
structure is not Intended or offered for sale(Section 7044, t_HANCIE .i_j:
Business and Professions Code). OWNERJai
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS (—(I_j.ly
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CI TEL.NO. �-" z y�
h4 ri
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
Lender's Name
CITY TEL.NO. % I
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. Z. CLASS
information is correct. I agree omply with all County ordinances
and State laws relating to g cons ction,and hereby authorize
re re entatives o this ty an upon the above-mentioned
p opa ty for i cC pu as. SEE REVERSE FOR EXPLANATORY LANGUAGE
(SIG U A ANT OR AGENT ...DATE