HomeMy Public PortalAbout10648 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate,�0 Wortkers'Compensation Insurance, HEATING - VENTILATING - AIR'CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9/88
Policy No. Company I I
Certified copy is hereby furnished. i COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING/"fr
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE I
✓ �y
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST U +--L�
COMPENSATION INSURANCE CROSS ST. G
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC D BY
the permit is For one hundred dollars work
or less.) J�V /�� /(
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit
U dNy.�
permit is issued, I shall not employ any person in any manner
so as to become subjje/eec�ct to the Workers'
/,Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Dat;?_Z_
/vApplicont._��, ��C/tel COMPRESSOR, BTU ��U ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER LI ATIO
with comp)y with such provisions or this permit shall be deem-
ed revoked. J FURNACE: FAU R ITY
LICENSED CONTRACTORS DECLARATION ` FLOOR BTU J�
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. i 0'0
License Number�
ic. Class Z G I , O
�liGi-v ;�t '_' 1�i
Contract Date I erO
❑ 1 am exempt under Sec. I U
Plan check fee Lu
B.BP.C. for this reason I a
PERMIT ISSUING FEE $ 4n
Date: �
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z5 o
I hereby affirm that I am exempt from the Contractor's License + ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS ACV-s
wages as their sole compensation,will do the work and CITY TEL. NO. {,loll
the structure is not intended or offered for sole(Section -3137
7044, Business and Professions Code). OWNER' C/ �'L% /Y/ / 1 ITEM,
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL TUT AL 6 1 o CIO
tion 7044, Business and Professions Code). ADDRESS r
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 61.00
1 hereby affirm that there is a construction lending agency for ti .{lL
the performance of the work for which this permit is issued CONTRACTOR . .G _ T , CHANGE
(Sec. 3097, Civ. C.).
ADDRESS l�fs
Lender's Name
Lender's Address CIb�l ✓ TEL :> G 1 AM 10 C 4 1
�
t6
I certify that I have read this application and state that the LICENSE NO.TE ,�7� CLASS �v3
above 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 a ove-m �enti ed property for inspection purposes.
n SEE REVERSE FOR EXPLANATORY LANGUAGE
C
Signature of Applicant or Agent Date