HomeMy Public PortalAbout9511 OLIVE ST_Mechanical__ _ " WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I he7dbK,affirm that I have a certificate of consent to self
1.
insure or dk:xertificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a, rtified copy thereof(Sec. 3800, Lab. C.) 76A364C t 11
CE-818(REV.. 10/81) Temple Cit
Policy Noi1C5109360 Company Select Ins. Co. 1°P y
Certified copy is hereby furnished. COUNTY OF LOS ANGELES + BUILDING AND SAFETY
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Certified copy is fi�lggd wit the c nt �µilding ins�g g FOR APPLICANT TO FILL IN i. BUILDING 11 Olive
tion de artment. a Z ego & 11� o ' ADDRESS 95
( (PRINT OR TYPE ONLY) I:
Date 10-30-84 Applicant LOCALITY Temple City ,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ;
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARS ST.TCit & Olive
COMPENSATION INSURANCE I Templey
(This section need not be completed if the or involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars(;100)or less.)
AIR HANDLING UNIT,CFM J 16
I certify that in the performance of the work forlwhich this' ,
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 INSPECT 'S IGNATURE
COMPRESSOR,BTU ROUGH
Date Applicant �✓
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 VALIDAT' N
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 SUSPENDED:, ( IT
( g ) 1 HEATER: WALL-M 7�/ yyt! �� 10,00
��y 9
'(commencing with Section 7000 of Division 3 of the Business a �
and Professions Code,and my license is in full force and effect. •Change Out #a i ()4 9 8 �
License Number 441678 Lic. Class C• 20 ,
Contractor. Heating Date 10-39-84 I o 0 2 Q 5 0
❑ I am exempt under Sec:
Plan check fee o o o 2 0.5 0 3.
8.8P.C. for this reason'
in
Date: 'PERMIT ISSUING FEE$ 10-50, Z
'
11,09-84 '
Signature TOTAL FEE °
OWNER-BUILDER DECLARATION 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):
ETI, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,wil I do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and.Professions Code). OWNER ° Ruth,P. Nelson
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 9511 Olive tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY - Temple City TEL. NO. 286- 34 .
I hereby affirm that there'is a construction lending•agency for Poo performance of the work for which this permit is issued CONTRACTOR George Brazil Plbgo & Heating
(Sec. 3097, Civ. C.).•
Lender's Name
ADDRESS 17420 SO. Broadway
'
Lender's Address CITY Gardena, 90248 TEL. NC515_0404
STATE 441678 LIC. C 20
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, i
and hereby authorize representatives of this County to enter
u n t above-mentioned property for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date