HomeMy Public PortalAbout9216 OLIVE ST_Mechanical__ WORKER'S COMPENSATION of consent to 76A364DPW 9f89 APPLICATION FOR PERMIT LIME GREEN
I herelfy affirm thfit I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
P❑0114 No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS l C� 0 VIE
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'
NEAREST
Ce S
e
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSORa
(This section need not be completed If the work Involved by the MAP BOOK 6 PAGE J IPARCEL
permit is for one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. 0
COMPRESSOR,BTU
LIQ ap
APPROVALS DATE INSP TOR'8 SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 34 q
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. n
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License Number Lic.Class J�jj''
011.
M4�i.•�0 4 a
Contractor Date 33137 94 223❑ CC-•I am exempt under Sec. Plan check fee
I iTEl�3 Ix
B.BP.C.for this reason PERMIT ISSUING FEE$ if
TOTAL 94 e 2 G5 FC-
Date: �. r—+ C
TOTAL FEE t 3 CNECK 94 n tti, LL
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Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .03 G
1 hereby affirm that 1 am exempt from the Contractor's License Law NAMEC ►
for the following reason (Section 7031.5, Business and Professions
Coe): ADDRESS U CN 0000-0001 11/13/9"
I, as owner of the property, or my employees with wages wFt
as their sole compensation, will do the work and the CITY _ C TEL.NO$ D�� 6471 1 AN 2 e4.51
structure is not intended or offered for sale(Section 7044,
JW Business and Professions Code). OWNER ,,
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS S�AM
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR Move:
q� ►
the performance of the work for which this permit Is issued Nova:fi
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
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
representati a of this County enter upon the al ova-mentioned
operty fo 1 ction purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE 0F APPLICA 0 AG: IL,4AT