HomeMy Public PortalAbout9317 OLIVE ST_Mechanical__ WORKERS;COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
irtsure, or a certificate of Workers'Compensation Insurance, HEATING — VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No.. Company
CTed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buil ing inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS C.! ® dL.^
Date!7 _Applicant LOCALITY Fs7 7
CERTIFICATE OF EXEMPTION FR /WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
COMPENSATION INSUR CE CROSS ST. L O
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSB
the permit is for one hundred dollars($100)or less.) CFM
I certify that in the performance of the work for which this AIR HANDLING UNIT, 566
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSP OR'S SIGNATURE
Date t /applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL `
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code; you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE:, FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPEND UNIT
'(commencing with Section 7000)of Division'3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class , 111P
_b 0
Contractor Date-lo/5 b
I am exempt#Vnar Sec. �
Plan check fee
y
B.&P.C. for this reason' PERMIT ISSUING FEE$ 10 5 �
Date:
Signature
TOTAL FEE :12.5 1.2 A
-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o o o o o
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME jAAMLESPoo ( o o 2 a 5 Q
Professions Code):
❑ I, as owner of The property, or my employees with ADDRESS ( �y o 0 0 20.505
wages as their sole compensation,will do the work and
the structure is not intended.or offered for sale(Section CITY TEL. NO.
a z
7,22-85
OWNER
7044, Business and Professions Code). 0,
❑ 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 AGENCYcITY TEL. NO
I hereby affirm that there is a construction lending agency for L-C P111111"the performance of the work for which this permit is issued CONTRACTO t
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name 1V
CITY TEL. NO.26 Q
Lender's Address STATELIC.
3 S
I certify that I have read this application and state that the LICENSE NO. CLASS
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 pr perty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ILJ
Signature of Applicant or Agent Date ,