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HomeMy Public PortalAbout9104 OLIVE ST_Mechanical__ °� ,�Nd*KERS'COMPENSATION DECLARATION 'vk�'ere6y affirm that I have a certificate of consent to self APPLICATION. FOR PERMIT tiw".- Ansure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof.(Sec. 3800 Lab. C.) 76A3&C /t�Q7 -� P� y CE-818(REV. 10/81) Policy Nal+ ompany lw/hN/ y 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 p� �+(/ tion department. (PRINT OR TYPE ONLY) ADDRESS / © 1 fJ E Date Applicant LOCALITY rLV� /Q 0,- NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE 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. PROCESSED BY the permit is for one hundred dollars($100)or less.) j. AIR HANDLING UNIT,CFM �. V I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner BOILER,BTU so as to become subject to the Workers'Compensation Laws. ,J APPROVALS DATE INSPE OR'S SIGNATURE Date Applicant I/ COMPRESSOR, BTUo�QiDc] �V ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /7 AX Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY o LICENSED CONTRACTORS DECLARATION I FLOOR BTU CCO I hereby affirm that I am licensed under provisions of-Chapter 9 SUSPENDED • UNIT HEATER: `(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,,and my license is in full force and effect. License Number V037175—7175— Lic. Class a+�u , U Y_ Contractor ���ND� Date (+ 11—� ❑ 1 am exempt under Sec. L Plan.check fee H B.&P.C. for this reason' PERMIT ISSUING FEE 9290, 1 A z Date: Signature TOTAL FEE 3 5 # o 0 0 0 0 8 � C OWNER-BUILDER DECLARATION PLANC�.",ECK APPLICANT I a 030,50 I hereby affirm that I am exempt from the Contractor's License - , Law for the following reason (Section 7031.5, Business and NAME o 0 0 3 Q 5 Q 5Professions Code): ❑l I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and 9. 12-8 5 CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code).. ;, i OWNER � Z L L ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADD SS Y CONSTRUCTION LENDING AGENCY CITY' � I hereby affirm that there is a construction lending agency for L /10TEL. NO. �r nn , the performance of the work for which this permit is issued CONTRACTOR C ,Ce (Sec. 3097, Civ. C.). ADDRESS 'f /y. Lender's Name d l • CITY P� /e (7 15e TEL. NO. Cr S/3� Lender's Address I certifythat I have read this application and state that the STATE LIC. �! pp LICENSE NO. I�37 CLASS � O 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I le /�7d ?-/z- l3S Signature of Applicant or Agent Date j