HomeMy Public PortalAbout9629 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or 9 certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof1Sec. 3800, b. C.)
6C 1�/TLI� 1 n� CE-818(REV. 10/81)
Polic No J V(/J bmpany �/
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy ifiled with the70IRKERS"
gZinsc- FOR APPLICANT TO FILL IN BUILDING 0A J %
tion departments. (PRINT OR TYPE ONLY) ADDRESS /5 i G
Date r(✓ Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTIO FRONEAREST •
COMPENSATION INSURANCE CROSS ST. Lv�(
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED 6Y
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this �i, O
permit is issued, I shall not employ any person in any manner BOILER, BTU gg
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE 1 bPECTOR' I ATUftE
Date Applicant
COMPRESSOR, BTU ROUGH G
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL !�
and Professions Code,and my lice�nssee is in full force
/and effect.
License Number �a 6 7 Lic. Class t ® to
Contractor! /L- Date g!!�Q " 2 8 1 2 4 8 0
❑ I am exempt under Sec. # a o a o 0 8 M
Plan check fee H
B.BP.C. for this reason PERMIT ISSUING FEE$ b I a o 2 0 5 O g
Date: , m
Signature TOTAL FEE a a a 2 Q 5 Ci 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 0.1 5-87
1 hereby affirm that I am exempt from the Contractor's License
Low 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.p
the structure is not intended or offered for sole(Section Q
7044, Business and Professions Code). OWNER
❑ I, as owner of the property,am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS Z!
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR � L/�
(Sec. 3097, Civ. C.).
ADDRESS Q Z� .yP
Lender's Name
CITY TEL NO
Lender's Address
STATE C LIC.
1 certify that I have read this application and state that the LICENSE NO. p CLASS C�
above information is correct. I agree to comply with all County
ordinances and State laws reJoting to building construction,
u� repr tatives of this County to enter
aboveione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Xgent Date