HomeMy Public PortalAbout10616 OLIVE ST_Mechanical__ 7B364
WORKERS'COMPENSATION DECLARATION I CEA Iz78C(2-80) Lam.��b=A�D®II tl ®� 11�7tl 0�
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIRCONDITIONINGcertified copy thereof(Sec.3800,Lab.C.)
Policy NcA%Zs"IyCompany. T.N3-pk.
El Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
42 Certified copy is filed with the county building inspection IBUI LDING
I FOR APPLICANT TO FILL IN ADDRESS
O�t V
i e�artrpe
Date �pplicant (PRINT OR TYPE ONLY)
LOCALITY �y!Pie— IU
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST >_COMPENSATION INSURANCE
(This section need not be completed if the work involved ABSORPTION UNIT, BTU ICROSS ST. �` aM1t'i��- a0
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO. PROCE D aY V
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner I O
so as to become subject to the Workers' Compensation.Laws. I { BOILER, BTU r
APPROVALS DATE, INSPECTOR'S SIGNATURE lJJ
D:tte Applicant I COMPRESSOR,BTUROUGH ^?0►- U)
NOTICE" TO APPLICANT: If, after making this Certificate ofZ
Exemption, you should become subject to the Workers' VENTILATION SYSTEM FINAL ^� —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and,
effect.
License Number10t+ Lic.Class
Contractor Qeb�� Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). ( PERMIT ISSUING FEE$
Lie,or Reg.No. DateI TOTAL FEE
HOME OWNS-R-BUILDER DECLARATION PLAN CHECK APPLICANT
1. hereby affirm that I ant exempt from-the Contractor's ' NAME
License Law for the following reason (Section 7031.5, Busi- 5 0 .1,0 A
ness and Professions Code): ADDRESS Qb tea. `
1, as owner of the property, will do the work and the �I o o 0 0 o B
structure is not intended or offered for sale (Section CITY C ;`` TEL.NO.
a;.. `t
7044, Business and Professions Code). OWNER 2'o - 3350
Aots `4
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project i MAIL �t � O`1Ve 0 0 0 3 " 0CJ
(Section 7044, Business and Professions Code). I ADDRESS
07. 1 6=8c
CONSTRUCTION LENDING AGENCY CITY'� le, �' TEL.NO.JWJ
I hereby affirm that there is a construction lending agency CONTRACTOR `� A Pq0
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS F +pati
Lender's Addresswp% CITY r./r TEL.NO.
1 certify that I have read this application and state that the STATE A. LIC. ��3
above information is correct.I agree to comply with all County LICENSE NO. �e � i CLASS G
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby auho4Da
iepresentatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Coun y to�Pona�o
tioned property forittcn i tion
\ Signature of 1'ermtttee te