HomeMy Public PortalAbout9624 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 C(2-BO) APPLICATION FO R PERMIT `
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
a cegte;iey1,copy thereof(Sec.3800,Lab.C A) lr
Policy Ntl Company � �'
C] Certified copy is hereby furnished. COUNTY OF LOS ANGELES / `- BUILDING AND SAFETY
&Re� copy is filed with the }�ty b 'Id' g inspection FOR APPLICANT TO FILL IN
department. 7N (PRINT OR TYPE ONLY) ADI
LDING
Date ApplicantCCCC�JJJJ DRESS
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LOCALITY T '
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. TG /l/ O
by the permit is for one hundred dollars ($100) or less.) (STRICT NO. PROCESSE By C.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cc
permit is issued, I shcll not employ any person in any manner 6-.• �� O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU C - H
APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,BTU ROUGH 'A N
NOTICE TO APPLICANT: If.after making this Certificate of VENTILATION SYSTEM ` h'
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be /�
deemed revoked. FURNACE: FAU GRAVITY l '
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: DED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- ALL �/9 YGj
ness and Professions Code, and my license is in full forceand
effect. ®�
License Num,/bera G�4 9/ Lic.Class -X//
Contractor 6-h4r---�Date �fp
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ (' -,5-c3
Lic.or Reg.No. Date TOTAL FEE Q S G
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from,the Contractor's I NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS AR 2 2 9.'2 A
I, as owner of the property, will do the work and the CITY TEL.NO. ` -
structure is not :intended or offered for sale (Section # o opo a o 8
7044,Business and Professions Code}
❑ OWNER 2 0 - 30.510
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS ° ° ' 3 0.5 0 U
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0'5.2 7—813
I heieby affirm that there is a construction lending agency t2 ice/
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3097,Civ.C.). G� /�
Lender's Name ADDRESS 7/®� s��//t/
Lender's Address CITY TEL.NSjp P7
I certify that I have read this application and state that the I
above information is correct.I agree to comply with all County LICENSE NO.��S� _99� C�SS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
iuspectio rposes. ;
Signature of Permittee Date