HomeMy Public PortalAbout9047 OLIVE ST_Mechanical__ . IVORKERS'COMPENSATION DECLARATION APPLICATION FOR P E RM I T
I�hel: Ytt`f(*m that I have a certificate of consent to self ,
insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) CE-'818(REV. 10/Bl)
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
tion department. ADDRESS 5& 60)1 Ve .
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Le
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCES96 BY
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this5&ls
permit is issued,I shall not-employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INy4CTOR'SJ1 RE
COMPRESSOR,BTU 4-ffd®0 B 6 4.s ROUGH
Date- Applicant I
NOTICE TO APPLICANT: If, after makin this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should 'become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR TU
I hereby affirm that I am licensed under provisiogs•of Chapter 9 SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
O.
License Number Lic. Gass ► V
®C
Contractor Date. ', z.9 4 4,,,1 A
❑ ' I am exempt undQt Sec. #• a 0.0 0 a 8 Lu
Plan check fee.
B.&P;C. for this reason' 1 - 3Q50
Date: `. PERMIT ISSUING FEE$ 6a �j o 0 0
3Q50�
Signature I TOTAL FEE 0 Q,2 2-8 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
Thereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ,
Professions Code):
i I, as owner of the property, ormy employees with ADDRESS
wages as their sole compensation,will do the work and
i the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
❑' I;as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and PPofessions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction,lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ.C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
I certifythat I have read this application and state that the STATE LIC.
pp 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
upon the above-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ISignatur f Applicant or Agent Date