HomeMy Public PortalAbout9566 OLIVE ST_Mechanical__ 1
y. 4 WORKER'S CdMPENSATION DECLARATION 064CPW9/89 APPLICATION rOR PERMIT LIME GREEN,
I hereb�-afffrm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy the,eoL(Sec:3800 Lab.10.) ��/yJ
Y �,-�2!/4d V, Y Gt,/V, 1! � I
Folic N Compan COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspecti FOR APPLICANT TO FILL IN BUL
DING
department. r (PRINT OR TYPE ONLY) ADDRESS
/ Applica LOCALITY 10
�j
Date/�" / 7 O. TYPE OF APPLIANCE OR EQUIPMENT FEE G
CERTIFICATE OF EX MPTION FROM WORKERS' CROSS ST.
COMPENSATIQN INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work involved by the ASSESSOR r`��
MAP BOOK dz PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to B ILER,PTU ��
become subject to the Workers'Compensation Laws. ,
`COMPRESSOR,BTU d APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,.you should become subject to the Workers'Compensation EVAPORATIVE COOLER If U
provisions of the Labor Code, you must forthwith comply with such FINAL +
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY s�S VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class 21 1
ACCT.a }
d�/ 3303
! f 3 0�I" 0-
Contract 1 /f �7�!J p,,// �t C)
❑ 1 am exempt under Sec. Plats Check fee U
v� LGA Nl`�tr i �tI 1`•:
B.BP.C.for this reason PERMIT ISSUING FEE$ lji f(7 ,� / TOTAL 106.L35 Q
Date: TOTAL FEE dlc �Jf C, r4,
CHECK il'!�a IJ� U
Signature CHANGE Cru al
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT r�r t r ILL ` Cr
I hereby affirm that I am exempt from the Contractor's License Law NAME /� 0(,� r
for the following reason(Section 7031.5, Business and Professions , W. ,], ;e C-ii13l,3—I�Ij1�1 +i/ +8�
Code): ADDRESS a
F1 1, 1964
(htll��r
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 47,t14�
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
F1 I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY l' TEL.NO.
I hereby affirm that there is a construction lending,agency for CONTRACTOR ,
the performance of the work for which this permit is issued r ,� Q�
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY r b
Lender's Address STATE V LIC.
I certify that I have read this application and state that the above LICENSE NO.�03� CLASs�
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereb authorize
representativ of this County t n r o. the abo m ned
proper pection r e SEE REVERSE FOR EXPLANATORY LANGUAGE
SI TUR O APPLIi NT OR AGENT ATE