HomeMy Public PortalAbout9217 OLIVE ST_Mechanical__ 1Ai ER'S COMPENSATION DECLARATION �6Ae64c PW 9/89 APPLICATION FOR PERMIT LIME GREEN
I ff'areby affin at I have a certificate of consent to self Insure,
or a certificate f Worke'kc 3 Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 LaD.6.1
Policy No. 12 46 r dCompany COUNTY 01FLOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F1 Certified copy is hereby furnished. '
❑ Certified copy is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUILDING �,-7 � OZ.4 V� �T
depart ent. y pp/ (PRINT OR TYPE ONLY) ADDRESS
Date Applicant � �^ C`4vL�' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALIM �i78O
TY Off ' (��/
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST r
CROSS ST.
COMPENSATION INSURANCE F-NC�//Vr�S
ABSORPTION UNIT,BTU ASSESSOR rJ,g► ��
(This section need not be completed if the work Involved by the MAP BOOK . 4000 PAGE PARCEL d;Ze
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU r�0
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPE GNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
7014-516 /¢ Ck74ysi oN 0ebucT
rys
1
License Number LID.Class u v
/farz PON.
Contractor Date 2 n
❑ I am exempt under Sec. Plan Check fee C
13
8.8P.C.for this reason
PERMIT ISSUING FEE$ 6,0 F
Date: TOTAL FEE D V
Signature PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION
6
1 hereby affirm that I am exempt from the Contractor's License Law NAME ® ,Qj
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS ACCT n 4
I, as owner of the property, or my employees with wages 4�i ��
as their sole compensation, will do the work and the CITY TEL.NO. LLre�
structure Is not intended or offered for sale(Section 7044, 1 ITERS
Business and Professions Code). WNER M4.R6�9,fr IMAM/F1 I, as owner of the property, am exclusively contracting MAIL -T TOTAL 48-30
with licensed contractors to construct the project (Sec- ADDRESS ?21 �, t01-1VZS!, CHECK 48.30
tion 7044,CONSTRUCTION LENDING AGENCY CITY /8
T�� L,� G'/y TELNO. z _ CHANGE .00
I hereby affirm that there is a constructions perm agency for ONTRACTOR �- !pyV71 //�� ,
the performance of the work for which this permit Is issued cam/ Y,/w`>
(Sec.3097,Civ.C.).
ADDRESS 1/l.S / h'/JLl/�/Y /F",�, 0000-0001 11/27/95
Lender's Name cin 5�/�=+�`Y EL.NO 8 03 3437 1 Ph112:09
el/wLender's Address STATE / LIC.
I certify that I have read this application and state that the above LICENSE N0.
7O (0 5� 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
proper ^f0 specti purposes. SEE SEE REVERSE FOR EXPLANATORY LANGUAGE
— — r — 6/14
SIGNATURE OF APPLICANT OR AGENT DATE