HomeMy Public PortalAbout9455 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I��f.,Jby'�af irm that I have a certificate of consent to self
insure, 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
Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspect- FOR APPLICANT TO FILL IN BUILDING
ADDRESS t -
tion department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' i NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED
the permit is for one hundred dollars($100)or less.) I C Q
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM "s ,
permit is issued, I shall not employ any person in any manner
so as to be4ome subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DTE INSPE OR'S SIGNATU
COMPRESSOR,BTU ROUGH
Date Applicant % - _..
NOTICE TO APPLICANT: If, after makind 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 VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked. / FURNACE: FAU GRAVITY- /�
LICENSED CONTRACTORS DECLARATION / FLOOR BTU (J
I hereby affirm that I am licensed under provisions of Chapter 9, HEATER:
SUSPENDED UNIT t
'(commencing with Section 7000)of Division 3 of the Business WALL l
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class ' V
Contractor Date
❑ I am exempt under Sec. ;21 28, 1 A d
� Plan check fee y
BAP.C. for this reason PERMIT ISSUING FEE Q 'd # 0 0 o 0 0 8 Z
Date: I - - 20,50
TOTAL FEE .�jQ
Signature _ o o 0 2 0,5 0 u
' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , 12 0 8—8 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with 'I ADDRESS
Wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section ,
7044, Business and Professions Code).
OWNER
I, as owner of the property,am exclusively contracting i MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY G TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this.permit is issued CONTRACTOR
(Sec:3097, Civ. C.).
ADDRESS �•
Lender's Name
CITY TEL. NO.
Lender's Address '
� STATELIC.
t ,
I certify that I•have read this application and state that the LICENSE N 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'e4
Signature of Ap' icant or Agent Date