HomeMy Public PortalAbout10566 OLIVE ST_Mechanical__ p' ORKI:I' COMPENSATION DECLARATION I CEA S78C(2-80) A P P l� C AT Q®1�l FOR PERMIT
I he�J —.4firm that I'have a' certificate of consent to self
-fn s ir�or anertificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a cPified copy thereof(Sec.3800,Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ,
department.
ADDRESS
Date Applicant (PRINT OR TYPE ONLY) • •
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST CROSS ST. d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. �t 1PROCESSED BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM OY
permit is issued, I shall not employ any person I a y manner O
so as to become subject to the W kers' om ion Laws. BOILER,BTU If
IF �� ROUGH APPROVALS DATE INSP CTORSSIGNATURE
Dat fflicant ' W
COMPRESSOR,BTU
NO 171 TO APPLICANT: If, after making this Certif ate of VENTILATION SYSTEMz
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU �1/)
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class I
Contractor Date
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ ;04752A
Lic,or Reg.No. Date TOTAL FEE # o o e o 8
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT J ° 0 3 Q 5 O
I hereby affirm that I am exempt from-the Contractor's NAME 3 Q,5 0 czr
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
❑ I, as owner of the property, will do the work and the 0 2 '�$b
CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL 1� ^
(Section 7044,Business and Professions Code). ADDRESS o.7
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTO
issued(Sec.3097,Civ.C.). r:
Lender's Name ADDRESS
29
Lender's Address CITY TEL.Nt ,
I certify that I have read this application and state that the STATE Vol LIC.
above information is correct.I agree to comply with all County I LICENSE NO. CLASS
ordinances and State laws regulating Heating,Ventilating and
Air Conditioning,an hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County It en er u inthe above-mentioned property for
i n pu p ses.
0P
Je
gna ure of Permittee Date o