HomeMy Public PortalAbout9557 OLIVE ST_Mechanical__ ..•,' CORKERS'COMPENSATION DECLARATION
y .� e6y;;ffirm d I-haCe,a certificate of consent to self APPLICATION FOR, PERMIT
In'ure, or a certificate of Workers'Compensation Insurance, HEATING — VENTILATING - AIR CONDITIONING
or certified copy•thereof e . 3 , Lab. C.) 6A364C
�� � 4 B18(REV. 10/81) i
Policy No�Law��n�Company � J� - .
Certified copy is hereby furnished.
-COUNTY-OF LOS ANGELES, ". BUILDING AND SAFETY
Certified copy is filed with the county-building inspec- I FOR APPLICANT'TO FILL IN BUILDING ;
tion department. ADDRESS
,, n ^ (PRINT OR TYPE ONLY)
DateLA Applicant Osa" y��" LOCALITr ���
NO. TYPE OF APPLIANCE ORsEQUIPMENT• FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST— i �
COMPENSATION INSURANCE CROSS ST.le L
(This section need ndtbe completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESS D BY
the permit is for one hundred dollars($100)or less.) �� �• (��� � (j
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I certify that in the performance of the work for-which this AIR:HANDLING UNIT,CFM J `. —N
permit is issued, I shall not em loy any person in any manner
BOILER,BTU
so as to become subject to th rkers'Com t, Lo APPROVALS D T INSPE OR'S SIGNAT E
Date` '�� A lean I COMPRESSOR, BTU I D ®'O` ROUGH
s 14 PP
NOTICE TO APPLICANT: I , I i c e VENTILATION SYSTEM FINAL
Exemption, you Should become subject he Workers' i
,. Compensation provisions-of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or"this permit shall be i
deemed revoked. FURNACE: FAU �pyl�Y
LICENSED CONTRACTORS DECLARATION FLOOR ' BTU J (N.��. to. 0 O`
'I hereb affirm that I am licensed under: rovisions of Cha ter'9 SUSPENDED UNIT
Y P P HEATER:
"(commencirig with'Section 7000)of Division 3 of.the Business WALL
and Professions Code,'and my license is in full force and effect.
IL
.License Number, Lic. Classes U
Contracts ,6& �` a`UaA LJ Date �c1t_
ElI•am exempt under Sec. ti'
Plan.check fee t .y
B.&P.C. for this`reason PERMIT ISSUING FEE$ z
i I 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): .
❑ I, as owner of the property;'or my employees with ADDRESS '
wages as their sole compensation,will do the work and _
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
El �Q` tiv
I, as owner'of the ro ert , am exclusive) contracting -
with licensed contractors to construct the project (Sec 'MAIL _ -=c� _ 5t•.•1
tion 7044, Business and Professions Code). ADDRESS .� � []�1 V 2. • _
CONSTRUCTION LENDING.AGENCY / ��b �3 +.E`. I_
CIT �i`n�� C-I TEL. :�n
+•:_.:,: --
Ihereby affirm that there is.a construction lending agency for
the-performance of the work for which this permit is issued CONTRACTOR ,M� ,
(Sec. 3097, Civ. C.). - .
ADDRE F. � �L
Lender's Name
ii II ii,� _�;-
!V a� TEL..NO.
CITY l�b l' ._.
Lender's Address _
I certif that I have read this application and state that the STATE LIC.
y pp LICENSE NO�'�� 'oQL 5 CLASS
above information is correct. I agre -to comply with all County
ordinances a tate laws rela g o building construction,
d hereb auth ri repre tiv of this,County to enter
n the bove n e pr ert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�. �..
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Sig Lure of App ant or Agent Date 1
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