HomeMy Public PortalAbout9863 OLIVE ST_Mechanical__ J
'WORKER'S I have
a certiIONficate
of consent to 2D-0076A346DPW9/89 APPLICATION FOR PERMIT LAME GREEN
76A384C
I hereby affirm that I have a certificate of consent to self insure,
or certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
�� �of(Se .3 0 L b C.) r
`f�olic�No. L�Company� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the cou buildin Ins action FOR APPLICANT TO FILL IN BUILDING
d a t . ,9 p 0 (PRINT OR TYPE ONLY) ADDRESS v
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY •�
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person In any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,youshould become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL (�
provisions or this permit shall be deemed revoked. FURNACE: FAU G AV�TY
LICENSED CONTRACTORS DECLARATION Q FLOOR VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. ,,y
License Number O Lic.Class
}
Contractor >Oate �.
ElI am exempt under Sec. Plan check fee C
B.&P.C.for this reason PERMIT ISSUING FEE$ L
Date: TOTAL FEE 6 a
a
Signature V.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages 31.37 x';1,11{.
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 1 ITEM-D
Business and Professions Code). OWNER TOTAL 5
.00
1, as owner of the property, am exclusively contracting MAIL + _
with licensed contractors to construct the project (Sec- ADDRESS •.)j���'`
tion 7044,Business and Professions Code).
F CONSTRUCTION LENDING AGENCY CITY / NO.�y ti•rt�(�E
I hereby affirm that there is a construction lending agency for CONTRACTORj/TEL.
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). / l+� �i:lit(t—{;_I�i j, 1/25/91
ADDRESS
Lender's Name CITY TEL.NO. 522`6 1 I-;I -r C 117
Lender's Address STATE :' LIC. `
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize I
repnesenta
flves of this County to enter upon the above-mentioned
o
r onUs. SEE REVERSE FOR EXPLANATORY LANGUAGE
SNT OR AGENT TE