HomeMy Public PortalAbout10619 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 r1 rA r, ��
76A364C APPLICATION FOR PERMIT it � �
I hereby.affirm that I have a certificate of consent to self insure, , ►7 L
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or a•eertificatd of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. 3 2.nt2d �ompany-3117 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county
9 Ip ADDRESS
building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY)
Date ( S�� Applicant � J1 L h M / LOCALITY G� pp - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L7
COMPENSATION INSURANCE 97ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM - DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU 5 fi
become subject to the Workers'Compensation Laws. — /dCl s
COMPRESSOR,BTU to
APPROVALS DATE INECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH n.��
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL QRZ
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION Of
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED L--- UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL r
Professions Code,and my license is in full force and effect.
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License Number ? 7 CLic.Class C'" / `_�/�%� G��G� o `44��
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Contractor 5i NLh A�L l9cA > , S�1W l'y� '�c. C
F1 am exempt under Sec. Plan check fee D
B.&P.C.for this reason PERMIT ISSUING FEE$ C
Date: TOTAL FEE t1CLl
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Signature U
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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1 hereby affirm that I am exempt from the Contractor's License Law NAME 111110.for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the 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 MAIL 8
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). CITY TEL.NO. 1 °�
CONSTRUCTION LENDING AGENCY 330-5 79.05
I hereby affirm that there is a construction lending agency for CONTRACTOR S, / LT , ITEMS
the performance of the work for which this permit Is issued C. 41 1-(6471111&7&7 i Ci
(Sec.3097,Civ.C.). ^ /� //��//J1
ADDRESS a L13 (A.'[/.q,0 L0C40.0 1)4 T 1 ly
Af 79 -05
Lender's Name /� �+ r
CITY TEL.NO.�O(9 $' I K 77a°05
Lender's Address STATE — LIC. r.1h;;r=
I certify that I have read this application and state that the above LICENSE NO. L
S5 ?j� S CLASS G�ZV �'r"•{ 11-11 E_ °DO-
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned 001E 01-0001 5/19/95
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S E1ri.j 1e3
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SIGNATU 0F AR113dCANT OR AGENT DATE