HomeMy Public PortalAbout9308 OLIVE ST_Mechanical__ WORKER'S COMPENSATION
certificate
of consent to "MUC l89 APPLICATION FOR PERMIT LIME ' GREEN
1 hereby,�affirm that 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.) ;
Policy No: Company COUNTY OF LOS ANGELES DEPT OF PUFiGC WORKS: BUILDING AND SAFETY•.,DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
LOCALITY �_m
Date Applicant L� C,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST ��S
CERTIFICATE OF EXEMPTION FROM,WORKERS' CROSS
ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSSR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �O
become subject to the Workers'Compensation Laws. j
COMPRESSOR,BTU O
Date Applicant 'APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
ACCToJL
s o
Contractor Date
❑ I am exempt under sec. Plan check fee 3303• 53.900
• B.aP.C.for this reason PERMIT ISSUING FEE$ �O Tt7TAL ITEhiS��o go
' D
v
Date: TOTAL FEE 3, CHECK X3.90 a
Signature PLAN CHECK APPLICANTU,
OWNER-BUILDER DECLARATION ' CHANGE ',00 Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS 0000-0001 6/27/96
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 7148 1 ACI 9:11
structure is not intended or offered for sale(Section 7044,
Business arid�Professions Code). OWNER L �T
r_1 I, as owner'of the property, am exclusively contracting MAIL
with licensed,contractors to construct the project (Sec- ADDRESS t
Ito n 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY G TELNO. D�
I hereby affirm that there Is a construction lending agency for CONTRACTOR GvV loo-
t
he performance of the work for which this permit s Issued
(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
representatives of this County to enter.upon the above-mentioned
property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI a1NNNrURE O�1 AGENT DATE , '