HomeMy Public PortalAbout9638 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818364C(2-80) APDLICAlTI®N FOR P E R WT
I hereby affirm that I have a• certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATI AIR CONDITIONING
��t:fied copythereof(Sec.3800 Lab .) �J ,
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+ 1
COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection BUILDING
d artment. I
FOR APPLICANT TO FILL IN ADDRESS g� DL V
Date ff`20' bZApplicant (PRINT OR TYPE ONLY)
i LOCALITY L�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
j CROSS ST. •
(This section-need not be completed if the work involved I ABSORPTION UNIT, BTU i3fJ L��%/(J CL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE BY U
I certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM L Q
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU i
n APPROVALS DATE INSPECTOR'S SIGNATURE W
Date ! Applicant COMPRESSOR,BTU N
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 11, Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must fortis- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that 1 am licensed under provisions of Chapter k HEATER: 8LLq2.EZ1 DED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and ?(�_
effect. i
Number IAL—
License Lic.Class
" i'
Contractor 4I'7Date g h t7 u{
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer i Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date I TOTAL FEE z3 ISO
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Awpw L✓ 6/
I 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 170 0 . /,.(.vi- OAK,
1, as owner of the property, will do the work and the c b 3 4 Ll A
structure is not intended or offered for sale (Section CITY ��Cne TEL.NO.[f(f(��G`Z(
7044,Business and Professions Code). � r '� o �0 0 0 0 $
OOWNER OD2E
I, as owner of the property, nm exclusively contracting l 2 0 0 2 3,5 0•
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS o o o 2 3 ,O 0�_,,
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0"220—8 2
CONTRACTOR
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is ��jQ i//y,Q//✓
issuedSSec.3097,Civ.C.).
Lenders Name ADDRESS 1-7v tj `I
Lender's Address CITY L1177pC,i�F'� TEL.NO.A46- b f 2
I certify that I have read this application and state that the STATE LIC. �s
above information is correct.I agree to comply with all County LICENSE NO. 3 s CLASS
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
inspection purpose
Sign re of Permittee Date
I