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HomeMy Public PortalAbout9622 OLIVE ST_Mechanical__ • WORKERS'COMPENSATION DECLARATIONjam® � • =.al!hef� p affi4P that 1 have a certificate of consent to self �© O ��` °��aTl®N FOR PERMIT insure, or a-certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING 'U .3or a certified copj/thereof(Sec. 3800, Lab'. C.) 76A364C U' / Rol•IRy:'N .Q P • drnpariy. pyltr�_ .��46 DPW 9/88 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec-' BUILDING tion depa tment. FOR APPLICANT TO FILL IN ADDRESS / q,��y��1 C ��ap (PRINT OR TYPE ONLY) �4L �■ Date le Z AppIICa�P�f4--VJ W3 LOCALITY TCM�pL�a G� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 'j �i CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST aa'' COMPENSATION INSURANCE CROSS ST. g C4 W M, ABSORPTION UNIT, BTU (This section need not be eompl@}@d If the work inVOIV@d by DISTRICT NO. J;PRF�SSED BY The permit is for one hundred dollars($100)or.less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM rjr permit is issued, I shall not employ any person in any manner d so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date' Applicant COMPRESSOR, BTU. ROUGH • •• 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 deem- .' ed revoked. FURNACE: FAU GRAVITY 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. and Professions Code,.and my license isin full force.and effect. License Number 3�Kq ii 7' . Lic. Class } d O ContrAt f ❑ , I am'exempt under Sec. R W/ u Plan check fee W BAP..C. for this-reason trn PERMIT ISSUING FEE $ Z "TOTAL FEE' Signature /9 b OW NER-136615ER DEC .RATION 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 CITY TEL. NO. ' the structure is not intended or offered for sale(Section 7044, Business and Professions Code). /� ^ �+ L .f/ !p 44�/y � �j�(i■a A OWNER d 4/ T J ❑ I, as owner of the property, am exclusively contracting -., ,� with licensed contractors to construct the project (Sec- MAIL 3307 11:1.013 tion 7044,'Business and Professions Code). ADDRESS ®LI5 i � � ' CONSTRUCTION LENDING AGENCY CITY' a` TEL. NO. 1 I hereby offirm that there is a construction lending agency for TOTAL 9®00 the performance of the work for which this permit is issued CONTRACTORpill. (Sec. 3097, Civ. C.). �.S (JG /Q. CHECK 7 ■ l�l, ADDRESS Lender's Name `� CHANGE ■u I CITY ��' ��. TEL. N�/OD. •• t� Lender's Address ' I certify that I'have read this application and state that the LICENSE•NO ?/STATE LIC. 1011000—Ow1 10/" 8Ji`fl, above information is correct.I agree to comply with all County ordinances and State laws relating to building construction, 3181 1 An 9- 411 and hereby authorize representatives of this County to enter upon the abov -m . ioned property for insp Fti purposes. t . 0 SEE REVERSE FOR EXPLANATORY LANGUAGE , 0 a Signa re of Applicant or Agent Date ION WORKER'Shave a certificate of consent to 76A348DPW9/89 APPLICATION FOR PERMIT LIME GREEN 76A384C I hereby affirm tlif3t 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 thereof(Sec.3800 Lab.C.) Policy No. Compan COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. Certified copy is filed with the?Inty building inspection FOR APPLICANT TO FILL IN BUILDING ' A de artmen (PRINT OR TYPE ONLY) ADDRESS v Date Applica . LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST. if ST COMPENSATION INSURANCE CROSS ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) I AIR HANDLING UNIT CFM DISTRICT NO. PROCESSED BY I-certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER,BTU �S become subject to the Workers'Compensation Laws. U COMPRESSOR BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL ` provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. A License umber 3 f 3 Lie.Class /3 / �O A , > Contractor Date (C Plan check fee I am exempt under Sec. ` C B.BP.C.for this reason PERMIT ISSUING FEE$ • L ta: TOTAL FEE d0 a Signatur - Cf OWNE UILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law NAME , for the following reason (Section 7031.5, Business and Professions L Code)' 'R ti— 1L ❑ 1, as owner of the property, or my employees with wages ADDRESS i^tL l�-, -' as their sole compensation, will do the work and the CITY •TEL.NO. 330-17 2.5.Q I structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNERI IEllS-'' a—i ❑ 1, as owner of the property, am exclusively contracting MAIL Tjt �� m CIO with licensed contractors to construct the project (Sec- ADDRESS y�a� F ��J Y tion 7044,Business and Professions Code). CITY TEL.NO. CHECK 25 n 1310, CONSTRUCTION LENDING AGENCY CHANGE ,,_; r I hereby affirm that there is a construction lending agency for �;-;1-; , (S� the performance of the work for which this permit Is issued CONTRACTOR (Sec.3097,Civ.C.). _ �� Lender's Name, ADDRESS 00110-0 0 i 4/_301/9# CITY TEL.NO.//,F, �j- �� Lender's Address 6705 f`c' I certify that I have read this application and state that the above LICENSE NO. � 3544 CLLASS information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned p erty for in ectio poses. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATU� APPLICANrOFFAGENT DAZE