HomeMy Public PortalAbout9461 OLIVE ST_Mechanical__ k '
'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I'hereby affirm that I have a certificate of consent to self
Ahsjure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof ec. 3800,�LLob. Com.) 76A364C
Jb s �p5_!if'�I��. 5� (REV. 10/81)
Policy Nb ocnpan �/
Certified copy is hereby'furnishe COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th my Wbuild' inspe - FOR APPLICANT TO FILL IN BUILDING
Tion department. ADDRESS
(PRINT OR TYPE ONLY) /�
Date Applica LOCALITY ' P Ll,r` 1) .1•
. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �.J
CERTIFICATE OF EXEMPTION FROM WORKERS' I ST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if;the work involved by ABSORPTION UNIT,BTU DISTRICT NO. %EIEID BY
AC
the permit is for one
hundred dollars(5100)or less:) �' ��
I certifythat in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation LOWS. APPROVALS DATE Lr INSPECTOR'S SIGNATURE
Applicant icant
COMPRESSOR,BTU � �� ROUGH
Date d-/,)-H I � uPJ `
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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G AV Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 - WALL y�
and Professions Code,and my license is in full force and effect.
101 I O
License Number Lic. Class.�✓� � � �. t;
Contractor Date
❑ I am exempt under Sec. tJ
us
Plan check fee r 11L
B.&P.C. forth r, son' �
PERMIT ISSUING FEE$
Dg
Signature 1 19
�/. TOTAL FEE
O NER-BUILDER DECLAIM ION PLAN CHECK APPLICANT _;. . -••••• --••-�••- -
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME -
Professions Code): - •�-
ADDRESS k �-� •� C
❑ I, as owner of the property, or my employees with "B 2�E 51.50
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).
El -
�,�
I, as ownOWNER er of the property, am exclusively contracting '(T �t—rtrLrL
rbRQ
with licensed contractors to construct the project (See- MAIL
DDRESS L �� - i0000-0001 9/22/$9
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CIT!TjjNpLg 6) TEL.N 1 l' 5864 1
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.).
AA `` ADDRESS 1 1; v
Lender's Name_TA� N
CITY A4 w I TEL. NO,
Lender's Address STATE LIC.
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
ordi nces and State laws relating to building construction,
a reby authorize re resent Ives of this County to enter
the a e- enti pr 6r o inspction pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applica or gent 9 to