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HomeMy Public PortalAbout9312 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-OD48 DPW 9/89 I hereby affirrp%kt I'have'a certificate of consent,to self Insure, ' „ .-APPLICATION�'FOR :PERMIT LIME GREEN or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab y) y �Poryly'�y- �V �`ompany �G� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. LJ Certified copy is hereby furnished. ❑ 9 P ADDRESS ��/ Z. Certified copy is filed with the county-buildin inspection FOR APPLICANT TO FILL IN .� dopa men „�� (PRINT OR TYPE ONLY) f yY- LOCALITY' Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 4 CERTIFICATE OF EXEMPTION FROM.WORKERS' NEARESTCROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed If the work Involved by the ASSESSOR MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. COMPRESSOR BTU �d��'© APPROVALS, DATE INSPECTO SIGNATURE - Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If,•atter making this Certificate of ROUGH ^l �- Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER T provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU Of GRAVITY / r , 706 LICENSED CONTRACTORS DECLARATION FLOOR BTU 'O (p VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL .Professions Code,and my license is in full force and effect. 3 -� "�/ ®v��12 `- r O License Number D 17 Lie.Class poll. O / /� y^ Contract / _S'4- : � r/Kate 7 C ❑ I am exempt under.Sec. Plan check fee C B.&P.C.for this reason PERMIT ISSUING J$ -1, -3e .3303 135010 F Date: TOTAL FEE /D 1 ITEMS u Signature TOTAL -35 m 10 u OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK . 135°10 I hereby affirm that I am exempt from the Contractor's License Law NAME e poll.for the following reason(Section 7031.5, Business and Professions �`� CHANGE .00 Code): ADDRESS ct V ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY—S; TEL.NOg P P.J'J7Z '0000-0001 12/ 6/95 structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ --�- S 3609 1 AM 9°44 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). CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there Is a construction lending agency for CONTRACTOR Pilo. the performance of the-work for which this permit s issued (Sec.3097,Civ.C.). r ADDRESS NJ Lender's Name CITY TEL.NO. . , Lender's Address STATE[LICENSE No. CLASS�� LIC. .I certify that I have read this application and state that the above G,r 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,"r upon the above-mentioned property or Inspectip purpo A SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR MENT