HomeMy Public PortalAbout9856 OLIVE ST_Mechanical__ ri —. .WORKERS'COMPENSATION DECLARATION r APPLICATION FOR PERMIT 4170 , �� •
eras affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof Sec. 3800 ab. C.) 6A364C
Q3 CE-818(REV. 10/81)
Policy No/ 75 Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND-SAFETY
Certifi d copy is filed with t county building inspec- FOR.APPLICANT TO FILL IN BUILDING S/
tion apart ant. (PRINT OR TYPE ONLY) ADDRESS b
Date Applicant
LOCALITY
NO. TYPE-OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WOR S' I NEAREST ti
COMPENSATION INSURANCECROSS ST.
(This section need not be completed if the work involved by II -ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
-the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM v�
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner BOILERBTU
So'O ,s to become subject to the Workers'Compensation Laws. APPROVALS DATE !NSPEfTORS SIGNATURE
Date Applicant I COMPRESSOR,BTU 60C e•• / 0
ROUGHal
NOTICE TO APPLICANT: If, after making this 'Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
.with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION.* FLOOR BTU U
I.hereby affirm that I am licensed-under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
'(commencing
USPENDED UNIT'(commencing with Section 7000)of Division 3 of the Business WALL ANT ;• �
and Professions Code,and my license is in full force and effect:
L
i a Number2( /Lic. Class , r 1 L( �'IL U
f
/ Date f!_(411_ �, .7'.�F, ... a� O
F-
-30
❑ .I am exempt under Sec.
Plan check fee i {CHECKI ±� IL
B.&P.C. for this reason' !.=� 1'•1 tr( Z
Date:
PERMIT.ISSUING FEE$ • (3 S-710' ,
TOTAL FEE 30 —1 C '
Signature Vit !' ! i
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;—C
I hereby affirm that I am exempt from the Contractor's License
•.1 F ) 4
Law for the following reason (Section 7031.5, Business and .NAME
Professions Code):
I, as owner of the property, or my employees with ADDRESS
El
wages,as their sole compensation,will do the work and CITY TEL. NO..
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL �/ U
tion 7044, Business and Professions Code). ADDRESS (p _
CONSTRUCTION LENDING AGENCY CIT TEL. NO �� S
I hereby affirm that there is a construction lending agency for. i '
the performance of the work for which this permit is issued CONTRACTOR p�
(Sec. 3097, Civ. C.). I
ADDRESS 7,zloe.
Lender's Name -�
'CITY EL. NO,,-?
Lender's Address
STATE LIC. r
I certify that I have read this application and state that the LICENSE NO. / / CLASS
above information is correct. I agree to comply with all County
Mgt
Jaws relating to building construction,
representatives of this County to enterioned grope ty for in tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
t I
nature of AppAgent Date
)