HomeMy Public PortalAbout10621 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 200--03046C PW 9/89 APPLICATION FOR PERMIT MjVI hereby affirm that I have a certificate ct consent to self insure, 7OA �� Eor a bertifidate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONINGLLLL���� GREEN.,
copy thereof(See..�380000 Lab.C.)
Policy No.J3)_J —38�..JCompany �G 11% COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING f� ) ,
Certified copy is filed with the county building Inspection (PRINT OR TYPE ONLY) ADDRESS
department. / P 1
_
Date Applicant LOCALITY � l
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION OM WORKERS' CROSS SST. C
COMPENSATION INSURANCE ABSORPTION UNIT.BTU
(This section need not be completed If the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
1 certify that in the performance of the work for which this permit d,
is issued, I shall not employ any person in any manner so as to BOILER,BTU —.!;:rP 7 � O
become subject to the Workers'Compensation Laws. Q
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE1
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 16-/47
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL • Z
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY D VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT—
(commencing
NIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL ✓II�
Professions Code,and my license is in full force and effect.
License Number 592%15 Uc.Class
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fQ!!R a
Contractor Sw oyi t�l�/FAt Data -Sl 1 1) C
❑ I am exempt under Sec.
Plan check fee 11
B.&P.C.for this reason PERMIT ISSUING FEE$ C
F-
Date: TOTAL FEE C
Signature PLAN CHECK APPLICANT V.
OWNER-BUILDER DECLARATION 2
1 hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason(Section 7031.5, Business and Professions
Coe): 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, u
Business and Professions Code). OWNER ACCT.S E.
❑ I, as owner of the property, am exclusively contracting MAIL a'rrlI-, -7O �
with licensed contractors to construct the project (Sec- ADDRESS ; 303 f 7.05
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. UENSJ
I hereby affirm that there is a construction lending agency for CONTRACTOR , TOTAL 79 .05
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). CHECK 79.05
ADDRESS !Fpa C 0♦� � !��'--�r�c
Lender's Name CITY TEL.NO.t709, - CHANGE � �
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. S `�� CLASS C— 0000-0001 5/19/95
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize 0512 1 AM 11 e 42
representatives of this County to enter upon the above-mentioned
property for' pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
sIqs�'
MGNA R OFAPPLICANT OR ENT DATE