HomeMy Public PortalAbout10561 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN;
76A384C
hereby affirm that I have a certificate of consent to self insure,
I certificals of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
)py thereof TSec.3800 Lab.C.)
Alcy No. CompanyCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
7 Certified copy is hereby furnished. n
7 Certified copy is filed with the county building inspection FOR APPLICANT T FILL IN
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department. (PRINT OR TYPE ONLY) ADSS ULLY) /✓
ate ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE c—C
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
'his section need not be completed if the work Involved by the MAP BOOK �� PAGE e,9-IF PARCELOW-3
armit is for one hundred dollars($100)or less.) 71 AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
issued, I shall not employ any person in any manner so as to BOILER,BTU
Dcome subject to the Workers'Compensation Laws. fn1 �jy
0- 18-93 _ COMPRESSOR,BTU V a O `� APPROVALS DATE INSP O OR'S SIGNATURE
ate Applicant `� VENTILATION SYSTEM
OTICE TO APPLICANT: If, after making this Certific �e of ROUGH O�Z�
xemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
rovisions of the Labor Code, you must forthwith comply with such FINAL �e..
rovisions or this permit shall be deemed revoked. FURNACE: FAU GRAV
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
;ommencing with Section 7000)of Division 3 of the Business and HEATER: WALL
rofessions Code,and my license is in full force and effect. ella
f C
Icense Number ] I� Lic.Class �" -' -
_ 13
') (� ACCTAL C
ontractor DateC.
o?
Plan check fee _J_, IZ2.-�.
I am exempt under Sec. d
B.&P.C.for this reason PERMIT ISSUING FEE F
C
Date: TOTAL FEE 11
Signature PLAN CHECK APPLICANT U
OWNER-BUILDER DECLARATION i ITEM'-_' G
hereby affirm that I am exempt from the Contractor's License Law NAME / •'a' '��
or the following reason(Section 7031.5, Business and Professions T-TRL -3 22o 25
ode):
e)' ADDRESS CHECK 1�1,_,
1, as owner of the property, or my employees with wages -ui
as their sole compensation, will do the work and the CITY TEL.NO. CHANGE
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER f��r
I, as owner of the property, am exclusively contracting MAIL 'O�6 I h ) �1
with licensed contractors to construct the project (Sec- ADDRESS V 1 a .t' r
tion 7044,Business and Professions Code). ) 11-57 . 1 ANI1 :.�
CONSTRUCTION LENDING AGENCY CITY '� i X `'� TEL.NO. ��(�.� �- 19 3
hereby affirm that there is a construction lending agency for CONTRACTOR f..L17
Ie performance of the work for which this permit Is issued Ld %J,L ( �
I 3087,Civ.C.). /
ADDRESS a� �`
mder's Name
CITY ( ,IA ( TEL.NO. J 4-
nder's Address STATE C' L C` 1
lertify that I have read this application and state that the above LICENSE NO. CLASS
ormation is correct. I agree to comply with all County ordinances
d State laws relating to building construction,and hereby authorize
wesentatives of this County to enter upon the above-mentioned
)perWor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e, `ewe._, oP
MATURE OF APPLICANT OR AG DATE