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Home My Public Portal About9725 OLIVE ST_Mechanical__ .� "WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT .rl• hereb)�affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a cerfif ed copy thereof (Sec. 3800, Lab. C.) 76A364C � Policy No.1004l11-g)7 Company-Chi-C "."-Vlp �d1S•�iAtn E-818(REV. 10/81) COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9 75 UiI ve/ tion department. (PRINT OR TYPE ONLY) ADDRESS �%J St Date r 7 Applicant kASS. BL-Irs, IVIC LOCALITY T� ,,e GI NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. GQ -en+/ c MJ (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO PROCESS sv the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. I BOILER,BTU APPROVALS DATE NSP OR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH �1 NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT with comply with such provisions or this permit shall be YONA deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. 9L e�kAdl� ducA wack A0 d O License Number 451$ Lic. Class 16) DR V%/ two roc�� 110KY #r aG ® Im Contractor 9,q U q:%marc, L/Date J11i&7 I am exempt under Sec. 22$Q 1,6A � Plan check fee ®- B.&P.C. for this reasonPERMIT ISSUING FEE$ #to 000a $ in Date: Signature TOTAL FEE ( o 0 2 x 5 0 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT `,, (� s I hereby affirm that I am exempt from the Contractor's License vv ��- Fes` -e ® o a o 2 G rj C 5 Law for the following reason (Section 7031.5, Business and NAME Professions Code): 0929-87 ❑ I, as owner of the property, or my employees with ADDRESS L_aS -TIAnLR S �r, wages as their sole compensation,will do the work and CITY �eYYI e ICI TEL.N (-61%)2,qF-9p the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ``rr [1 `_ ❑ I, as owner of the property, am exclusively contracting MAIL It with licensed contractors to construct the project (Sec- ADDRESS 5704 Go den est tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY !e CAN TEL. N .� 2$'7-�� I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR A c , 4 I (Sec. 3097, Civ. C.). DkW ADDRESS q0ILf;�_ 1 �s�. �"rAV �. Lender's Name I—�� [LICENSE TY "rem a ;. TEL. NO& 2215-1041 Lender's Address _ ATE ff LIC. 1 certify that I have read this application and state that the NO. fj�O CLASS e 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ION WORKER'S I have a certificate of consent to 7SM84DPW 9/a9 APPLICATION FOR PERMIT LIME GREEN I hereby affirm that 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.) "0 Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING / C tY 9 P ADDRESS l.JliL l4Y! department. (PRINT OR TYPE ONLY) LOCALITY IMF— Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST U>---.T n 1,._T 9t CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. („1(/s��r COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU �j �' become subject to the Workers'Compensation Laws. / �Qa CGG�iL� COMPRESSOR,BTU 4 5f, 0 0 � Date Applicant APPROVALS DATE INSPECTOR'S SIGNATURE PP VENTILATION SYSTEM NOTI E TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LI VAATION LICENSED CONTRACTORS DECLARATION FLOOR BTU (O 1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL l (j Professions Code,and my license is in full force and effect. 7 IL Aee License Number--4-4T.1q.. Lic.Class ®ZIP 3 e j% 7"_r:rLt� r °7-- � ! IT EN' C Contractor Zy V C-Date ' -3- ❑ Plan check fee TOTAL 7,� a 7C C I am exempt under Sec. r/ I_I�Gr_ "?°~I_F BAP.C.for this reason PERMIT ISSUING FEE$ G ate: TOTAL FEET) CHAKE Signature ` G PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION s� I_),I'I_-013t_ 'i 1 V 1 hereby affirm that I am exempt from the Contractor's License Law NAME �/, / l/�y- for the following reason (Section 7031.5, Business and Professions `�' VG P-A C vv f ® 214i�� i AM 1°r^ Code): ADDRESS / LP 0 Q's ❑ 1, as owner of the property, or my employees with wages t as their sole compensation, will do the work and the CITY L T L.NO-b 131 structure is not intended or offered for sale (Section 7044, a Business and Professions Code). OWNER �� LAIJ ❑ I, as owner of the property, am exclusively contracting MAIL �� • with licensed contractors to construct the project (Sec- ADDRESS ��JJLJ��►,Q tion 7044, Business and Professions Code). ,�. CONSTRUCTION LENDING AGENCY CITY _QNw TEL.NO I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit is issued (Sec.3097,Civ.C.). ADDRESS �� 0 Lender's Name CITY r � , TEL.NO X'I Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS P �J information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this Coun to enter upon the above-mentioned properly o •nspecti ur es. r SEE REVERSE FOR EXPLANATORY LANGUAGE � 2 It 0131, SIGNATURE OF APPLICANT OR AGENT DATE