HomeMy Public PortalAbout9426 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 7OA364C PW 9189 APPLaICATI®N FOR PERMIT ����,�� /a I D
I hereby affirm that I have a certificate of consent to self insure, _ �1/� ((�
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 PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BDDRESDING
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department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. .
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL r Z
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL �- 09
Professions Code,and my license is in full force and effect.
License Number Lic.Class =
C
Contractor Date
❑ I am exempt under Sec. Plan Check fee B
B.fl<P.C.for this reason
PERMIT ISSUING FEE$ alp ZQ
Date: TOTAL FEE D
Signature q
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
^� 6
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions ��•fes' °
Coe): ADDRESS `}�,`.'07 +1s rlc
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. i 'T';-Eril,_
structure is not Intended or offered for sale(Section 7044,
.
Business and Professions Code). OWNER II�IV.AL 52. 05
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS � jv��" NECK --
°
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tion 7044,Business and Professions Code). (_;'ANG ,D
CONSTRUCTION LENDING AGENCY CITY �� /Z (, C L.NO.�/� �SG/
1 hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS 7937
Lender's Name t t
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
ZNATUt.2..1
y for�ins action purpo s SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLICANT OR AGENT DATE