HomeMy Public PortalAbout10627 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 C(2-8d A PP L ICATJO �I FOR PE R tl`iIl!� II
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No.OiWC Company5wa112p- L)"o.uAl �1tH.lJ�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN
((������ ����,(���,,,,�� ADDRESS ,
Date"ga!3-% � ApplicantaxwaI'= moi` i (PRINT OR TYPE ONLY)
{V/ LOCALI�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO68,
CESSE BY O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM !`-" V
permit is issued, I shall not employ any person in any manner / cc
so as to become subject to the Workers'.Compensation Laws. BOILER, BTU 0
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTU
ROUGH W
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM N
Exemption, you should become subject to the Workers' FINAL / l Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ALID TION
with comply with such provisions or this permit shall be
deemed revoked. i FURNACE: FAURAVITY
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- i WALL
ness and Professions Code, and my license is in full force and !
effect. 1
License Number iQQQ28 Lic.Class- C'QD
Contractor . L Date st.t,l i���
F1 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
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 3 Q
1 hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the '�jO* .
structure is not intended or offered for sale (Section CITY TEL.NO. 33607 -orf° 0
7044,Business and Professions Code). �3i.1 ,.5w
❑ OWNER 1 ITEM
I, as owner of the property, am exclusively contracting �^
with licensed contractors to construct the project MAIL TOTAL 30.50
(Section 7044,Business and Professions Code). ESS/0(,�,97 E �
CONSTRUCTION LENDING AGENCY ITY _ TEL.NO. CHECK 30"511
I hereby affirm that there is a construction lending agency C' E ■00
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRE S L r ��
-owl 8/18/89
Lender's Address CITY A41JJL.NO Ift Sg_Wjlp 5163 1 AIS48
I certify that I have read this application and state that the STA E LIC. I
above information is correct.I agree to comply with all County LICENSE NO. CLASS —
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and ereby authorize representatives of this l SEE REVERSE FOR EXPLANATORY LANGUAGE
Codi rtty—to, er t tlt above-mentioned property for
>spection pos -
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,. tB mit a Date
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