HomeMy Public PortalAbout9842 OLIVE ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C - /� - '
'I hereby affirm that I have a' certificate of consent to sel€� �;, CE-`S B(2-80) APPLICATION FOR PERMIT
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800;Lab.C.)
Policy No. Company
Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the ADynty buil ing inspection i BUILDING
� fix —�� � �� FFORAPPLICANT TO FILL IN
Dat Applicant (PRINT OR TYPE ONLY) ADDRESS
Z"—
CERTIFICATE OF,EXEMPTION FROM WORKERS'
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYOC
COMPENSATION INSURANCE NEAREST
CROSS ST. ��/�``d�
(This section need.not be completed if the work involved ABSORPTION UNIT,BTU p
by the permit is :for' one hundred dollars (S'100) or less.) DISTRICT NO. PROCESSED Y U
I certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM
permit•is issued;I shall not employ any,person in any manner O
so as to becdme'.subject to the Workers'Compensation Laws. BOILER,BTU'
APPROVALS DATE INSPECTORS SIGNATURE, W'
Date Applicant �. COMPRESSOR;BTU ROUGH / ��Ss
NOTICE TO APPLICANT:•If, after making this Certificate of ! VENTILATION SYSTEMIL Z
Exemption,' you should become subject to the Workers' ' II FINAL ,31C ` y-
Compensation provision's of the Labor Code,you must forth- I '
EVAPORATIVE COOLER. VALIDATION
with comply with such provisions or this permit. shall be
deemed revoked. _ '
LICENSED CONTRACTORS DECLARATION FURNACE:. FAU GRAVITY "
t FLOOR: BTU
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 rr
effect.',. t
License Number ` Lic.Class `
r Contractor• Date
I am exempt from the licensing requirements.as I am a c
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
I :,iness and Professions Code). PERMIT ISSUING FEE$ ;.
Lic,or Reg.No. Date F TOTAL FEE `
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
JZ
I hereby affirm. that I.am exempt from-the Contractor's ;, NAME
r Liceiise,Law for the following reason (Section 7031.5, Busi- i' n u o, u a 6ness and Professions Coda):' ADDRESS
I, as owner of the property, will do the work and the i L " ° 'a v 0
structure is `not intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code). \ 41 O '
OWNER ���S
I; as owner of the property, am exclusively-contracting I r ) n
with licensed contractors"to construct the project MAIL pF'� /Y�� �'
(Section 7044,Business and Professions Code). ! DDRESS l(J [/
CONSTRUCTION LENDING AGENCY CITY. ' TEL:NO.
I hereby affirm that there is a'construction lending agency CONTRACTOR
,,at!`_
for the performance of, the work for which this permit is I �v`'
issued SSec.3097,Civ.C.).
Lender.s Name ' I ADDRESS Vr/&,�7
Lender,'s Address I CITY "rj.✓ 1 TEL.NO `7-7440
.I'certify that I'have read this application and state that the S ATE 'L LIC.
above information'is correct.I agree to comply with all County LICENSE NOI��T GLASS
;ordinances and State laws regulating Heating;Ventilating and
`Air Conditioning, p SEE REVERSE FOR EXPLANATORY LANGUAGE t
and hereby authorize representatives of this
County'to enter upon the .above-mentioned property for ,G ,
Signature of'Permittee Date I _