HomeMy Public PortalAbout9070 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 2001M6DPW 9,B9 APPLICATION FOR PERMIT LIME GREEN
• 78A364C
I hetehy firm that'! have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.c.) . HEATING-VENTILATING-AIR CONDITIONING
't 1100
Polipq No. ---Company rU.t(O COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is.hereby furnished.
❑ Certified co Is filed with the coun buildin inspection FOR APPLICANT TO FILL IN BUILDING.
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departmen copy 9 p (PRINT OR TYPE ONLY) ADDRESS V C/
Date r .-- pplicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY C
CERTIFICATE OF EXE T N FROM W ER NEAREST ) '
COMPENSATIO INSURANCE CROSS ST. (�
ABSORPTION UNIT,BTU ASSESSOR p
(This section need not be completed if the work involved by the MAP BOOK 3�0 PAGE PARCEL JAL9PX(
permit is for one hundred dollars($100)or less.) I AIR HANDLING UNIT,'CFM
DISTRICT NO. I PROCESSED BY
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to 1! BOILER,BTU p
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU �J
APPROVALS DATE INs R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH ,
Exemption,you should become subject to the Workers'Compensation ' EVAP,ORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR ' BTU /057 VALIDATION
hereby affirm that.I am licensed under provisions of Chapter.9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business ad HEATER: WALL
Professions Code,and my license is in full.force and effect.
ACCT..&
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License Number .:
. LID.Class. i �g , � 303 j 1u n 2�
I ITEM o
Contractor. ate C
El Plan check fee TOTAL -•--�-22 dc
I exempt un ec. a
B.&P.C.for this reason PERMIT ISSUING FEE$ 00 CHECK 118,20 FC-
i RANGE nj]Ot
Date: I TOTAL FEE ,
Signature //
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT d 0000-0001 2
6/933
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions , I � 1 (['�i(jv�t�#
Code): ADDRESS
❑ I, as owner Of the property, or my employees with wages
as 1heir'sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered-for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I.hereby affirm that there is a construction lending agency for CONTRACTOR t
the performance of the work for which-this permit Is Issued bO
(Sec.3097,Civ.C.). if
ADDRESS /-2 /1 ��
Lender's Name C -Ir V
CITYC TEL.NO.Cie 2
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI6NA�APPLICANT���.ATEE