HomeMy Public PortalAbout9341 OLIVE ST_Mechanical__ WORKER'S COMPENSATION
ate of consent to 7SM66DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A384C
I hereby affirm that:l have a certificate of consent to self Insure,
or certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy Nom �� �
05 Company >wot�AM-ly COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
LI Certified copy is filed with the c ty bulldin Inspection FOR APPLICANT TO FILL IN AUILDING
DDRESS '15-4 �LI�lG
department. (PRINT OR TYPE ONLY)
— !� Applicant
Date 12-3 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY — Egg ILC GL'i
NEAREST
CERTIFICATE OF EXEMPTION F M WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that In the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER BTU �� O
become subject to the Workers'Compensation Laws. O
COMPRESSOR,BTU S_CP,oo a
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �•�d
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU tPoo VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
• -1 1n1L$C' aL<ri�C I
License Number C>8n15Gf LID Class G ZOO
CL
Contractor ( �'Dae �
11^`3 , C
Plan check fee
❑ I am exempt under Sec. Im
B.&P.C.for this reason PERMIT ISSUING FEE$. r� II
Date: TOTAL FEE _ OW.
Signature PLAN CHECK APPLICANT Ae 1p.D Cr
OWNER-BUILDER DECLARATION 2
I hereby affirm that I am exempt from the Contractor's License Law NAME , .2
for the following reason (Section 7031.5, Business and Professions
i.
pr
Code): ADDRESS HSL :F
❑ I, as owner of the property, or my employees with wages -, �! I
as their sole compensation, will do the work and the CITY TEL.NO. - C,-,
structure is not intended or offered for sale(Section 7044, 1 ITEM
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contractingMAIL T�I m
05
with licensed contractors to construct the project (Sec- ADDRESS OLJ � - s �,,�• fj
lrrG si4
tion 7044,Business and Professions Code). M6.05
CITY' • �
CONSTRUCTION LENDING AGENCY 1�rA. L� e i TEL.NO. � _yy 3E
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit s issued tJIG�rL
(Sec.3097,Civ.C.). �{•�
ADDRESS I-It,) trf-01001 9 i/ J/i ti+
s
Lender's Name •I �f.{
CITY , i-., 1�Q TEL.NO.q 1,r._s &p 2Oi 23 t P i l+':10
Lender's Address STATE �J�+ LIC. f 'T
I certify that I have read this application and state that the above LICENSE NO. /v�Co CLASS G�Zv
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
prop for insp Man purpos s. �] 2 SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE APPLICA T OR AGENT DATE