HomeMy Public PortalAbout10643 OLIVE ST_Mechanical__ ION
WORKER'S I have
a certificate
of consent to 7W64 DPW 9/89 APPLICATION FOR PERMIT LME GREEN.
I hereby affirm that I have a certificate of consent to self insure, 78A3fS4C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. I (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT.BTU
(This section need not be completed if the work Involved by the ASSESSOR
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM MAP BOOK PAGE PARCE '
DISTRICT NO. PROCE BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL (Q
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALID TION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and f WALL
Professions Code,and my license is in full force and effect.
License Number LiD.Class
I p a
Contractor Date Q
❑ I am exempt under Sec. Plan Check fee ri CT a
B.ff,P.C.for this reason PERMIT ISSUING FEE$ — ��i� u =il(I H
Date: TOTAL FEE d i i IT LL
Signature TOTAL 32 = 00- D•
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT V.
CHECK
I hereby affirm that I am exempt from the Contractor's License Law NAME
for following reason (Section 7031.5, Business and Professions , HfiE
de ADDRESS 1 '
CNG
1, as owner of the property, or my employees with wages A
>24
as their sole compensation, will do the work and the CITY I 1AA TEL.NO. : �k 41
structure is not intended or offered for sale(Section 7044, 0 313i� '001 i 1116/9 1
Business and Professions Code). OWNER %�] j AN 10`e i•'_
F1 Business
as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). I
CONSTRUCTION LENDING AGENCY CITY ,t—t c TEL.NO. V v
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
[STATE
TEL.NO.
Lender's Address LIC.
I certify that I have read this application and state that the above NSENO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives a
_21.1kis County to ant upon the above-mentioned
property r' pe on purposes / SEE REVERSE FOR EXPLANATORY LANGUAGE
r
eIG R OR AGE DATE