HomeMy Public PortalAbout9556 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self -
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or r led cop t reof(Sec. 3800, Lab. C.) L64C
5T�"rr_ �jX/� E-818(REV. 10/81)
P o. any Comp
Certified copy is hereby furnished. COUNTY OF LOS ANGELES ` BUILDING AND SAFETY
-RAN!7
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date �O -3 43 Applicant &M4V
LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �J a
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
7.
(This section need not be completed if the work involved by � «
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this r
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 INSPECTOR'S SIGNATURE
COMPRESSOR,BTU O U a 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 VALIDATION
with comply with .such- provisions or this permit shall be
deemed revoked. FURNACE: FAU_X_GAVITY 7tT.
LICENSED CONTRACTORS DECLARATION FLOOR BTU G
I hereby affirm that I am licensed under-provisions of Chapter 9SUSPENDED UNIT
`(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect. i
License Number VO 7 �7 Lic. Class C�� ► U
014v F_ K i M fL tie
Contractor HnfAlr I ho Date �V-3-Sr 3 0
❑ I am exempt under Sec.
Plan check fee
B.BP.C. for-this reason'
PERMIT ISSUING FEE; �G
Date:
Signature TOTAL FEE LIS Il
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):
El1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 7
the structure is not intended or offered for sale(Section (CITY TEL. NO. I
7044, Business and Professions Code). I n
OWNER .0 Lk 14
❑ I, as owner of the property, am exclusively contracting I
with licensed contractors to construct the project (Sec- IM'AIL ESS i-Jt r /'' ° C4"C
tion 7044, Business and Professions Code). ADDRr r
CONSTRUCTION LENDING AGENCY ;CITYTEL. NO.
I hereby affirm that there is a construction lending agency for I 1+ ` 000 I (1
the performance of the work for which this permit is issued CONTRACTOR ( p C .��K'
(Sec. 3097, Civ. C.). /
ADDRESS 7 0 e•/; O ox,
.
Lender's Name
Lender's Address (CITY 1' r TEL.N6 17�Z�
LIC
I certify that I have.read this.application and state that the �LICCENSE NO. d C TE A /SS Y5S.
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and h by authorize epresentatives of this County to enter
upon a above-hie d-prop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
o -3 .-,F,3
Signoture of Applicant or Agent Date I 1