HomeMy Public PortalAbout9041 OLIVE ST_Mechanical__ yY'WORKER��S'�CC�MPE�ISATION DECLARATION APPUCATI®h FOR PERMIT
'µA igSure 6 afcei ifi2ate.of Workers'1Compen Compensation Insurancificate of consent to e,
or a certified copy thereof.(Sec. 3800, Lab. C.) 76A364C HEATING - !VENTILATING - AIR CONDITIONING
CE-818(REV. 10/81)
Policy No. - `company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 19A ) �.
tion department. (PRINT OR TYPE ONLY) ADDRESS
IV
Date pito-?( Applicant LOCALITY Zgflt" 1/111A
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO7FM WORKERS' NEAREST
COMPENSATION NCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. C/ PROCESSE
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM x
I certify that in the performance of the work for which this Ste
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSP CT SIGNATURE
Date Applicant COMPRESSOR, BTU Od d ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' ^I dd
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER #A I ION
with comply with such provisions or this permit shall be �V
deemed revoked. FURNACE: FAU T 1
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT—
'(commencing
NIT'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class , U
09
Contractor Date
❑ I am exempt under Sec. (J
Plan-check fee Q.
Q.
H
B.&P.C. for this reason' �
PERMIT ISSUING FEE Q d �3 7 5 8 A
Date: TOTAL FEE 2 9a # o o o 0 0 8
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT :I o o 3 0 5 0
I hereby affirm that I am exempt from the Contractor's Licensep n , o 0 o 3 0 5 0
Law for the following reason (Section 7031.5, Business and NAME UE5 V S mo!C [r
PP fessions Code): 0 1.06-86
I, as owner of the property, or my employees with ADDRESS ®(t ( _�� 0(_I� I S r
1/ wages as their sole compensation,will do the work and CITY 7S nL t TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER —X US O IM
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL S 7
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY � EL. NO.
I hereby affirm that there is a construction lending agency for t
the performance of the wort r which this permit is issued CONTRACTOR 5 dV ,
(Sec. 3097, Civ. C.
ADDRESS
A.
Lender's Name
ess CITY L. NO.
Lender's Addr
I certify that I l9ve read this application and state that the STATE LIC.
LICENSE NO. CLASS
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
qtLhe bo - entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
of Applicant or Agent Date