The URL can be used to link to this page

Home My Public Portal About9625 OLIVE ST_Mechanical__ ,,fi�ee ,,yy�� , WORKERS'COMPENSATION DECLARATION 7BA g g(2-80) ��`�s6'1�I®1�I FOR ��II I#�� I Atetva�y affirm that I have a• certificate of consent to self CE- instge, dr a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDMIONING I I a colp1thereof f(Sec.3800,Lab.C.) lJ Icy 0.A& ompany l'o/t AMIL4 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY �r Certified copy is filed with the county building ins ction FOR APPLICANT TO FILL IN BUILDING ADDRESS !� aep�r7t ensy.� L s Dae Applicant _ , V� (PRINT OR TYPE ONLY) 0"p- FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT COMPENSATION INSURANCE NEAREST 7-6 J >_ CROSS ST. / C / (This section need not. be completed if the work involved ABSORPTION UNIT, BT u a by the permit is for one hundred dollars ($100) or less.) DISTRICT . PROIS V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 00 permit is issued, I shall not employ any person in any manner 1 so as to become subject to the Workers' Compensation Laws. BOILER,BTU APPROVALS DATE INJECTOR'S SIGNATURE V Date Applicant COMPRESSOR,BTU ROUGH d NOTICE TO APPLICANT: If; after making this Certificate of VENTILATION SYSTEM z Exemption, you should become subject to the Workers' FINAL Z 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 V by LICENSED CONTRACTORS DECLARATION FLOOR: BTU d `� I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license.is in full force and ,D / (� /7 i9 effect. 03 7.1S �, License Number /✓ Lic.Classy t?� I. Contractor 00,6411-ADate P: 3a�g� q44".4 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 U tl Lic.or Reg.No. Date TOTAL FEE :3CJ7 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t � I hereby affirm that I am exempt from-the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ACCT■A ness and Professions Code): ADDRESS DI, as owner of the property, will do the work and tfie O. =7 39° structure is not intended or offered for sale (Section CITY TEL.N39.15+ ITEM 7044, Business and Professions Code). 1 1 G tS ❑ OWNER I, as owner of the property, am exclusively contracting 2 � �� TOTAL 3 9.7 1,5, with licensed contractors to construct the project MAIL /+ (Section 7044,Business and Professions Code). ADDRESS (a (le- CHECK 39.75 CONSTRUCTION LENDING AGENCY CITY I a &ef TEL.NO. CHANE ■00 I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is .4/Z fk yNZC /1►fL issued(Sec.3097,Civ.C.). �w/ t'u-'tom, nth n Lender's Name ADDRESS 9 Ni rev GN1 f� 0000-0001 10/24/V9 Lender's Address CITY A► /G e7g t TEL.NO.;?&—.? 6311 1 A1111:53 I certify that I have read this application and state that the STATE a LIC. above information is correct.I agree to comply with all County LICENSE NO. 0 3 7 CLASSrJC Jf 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 m ct' n pur osess Sig ature.of Permittee Date &61VIM? /912 Calm .T�t 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 t' 'ed copy thereof(Sec. 3800, Lab. C.) 76A364C yy�� (' CE-818(REV. 10/81) Policy o. 1 1 �`�'Company .7a/� a' 2 ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING t rn tion /department. /a (PRINT OR TYPE ONLY) ADDRESS ! U Date Applicant d2 %L LdN� LOCALITY _rc NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PRO ED t3Y the permit is for one hundred dollars($100)or less.) ` AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. I BOILER, BTU APPROVALS rfATE 40000 INSPE OR'S SIGNATURE I Date Applicant COMPRESSOR,BTU 11191 OL ROUGH n r •• � NOTICE TO APPLICANT: If, after making this Certificate of VENT8ATION SYSTEM FINAL I Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIdATION) with comply with such provisions or this permit shall be / deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT HEATER: '(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. License Number a.3 23-C Lic. Clas C 0 1010. LP Fq-coRd Contractor B D2 Date L��e " `� ❑ LU 1 am exempt under Sec. �� LUPlan check fee N B.&P.C. for this reason Date: PERMIT ISSUING FEE$ 49 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 PP Professions Code): -t ❑ I, as owner of the property, or my employees with ADDRESS ACC��' I o s wages as their sole compensation,will do the work and NO. nt: the structure is not intended or offered for sale(Section CITY TEL. 3307 �5 0Z_1 7044, Business and Professions Code). OWNER � 27` ITEMS ❑ I, as owner of the ro ert am exclusive) contractin g 1,,r-4 with licensed contractors t construct the project (Sec MAILADDRESS ! a//,l� TOTAL 25 a � 113 tion 7044, Business and Professions Code). s CONSTRUCTION LENDING AGENCY CITY '—� TEL. NO. �C_ CHECK j .013 I hereby affirm that there is a construction lending agency for ' , CHANGE ,Q[i the performance of the work for which this permit is issued CONTRACTOR d 2 (2 [ �N /If L (Sec. 3097, Civ. C.). /0 r�1 / ADDRESS 3 Lender's Name /i/" I1313111310-101001— `Vl�� 't P `r= i 90 L q r CITY Gr� �/� TEL. NO.`I p j,- � S 0396 Y AM 9-Lia'.• Lender's Address {' TATE LIC. I certify that I have read this application and state that the LICENSE NO. y0 S' CLASS !,)_O [° s above 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 u the above-m d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent TDatte// /'211 AI/JAn Jl / A /'7 J i Af _l/Y c+ -�