HomeMy Public PortalAbout9915 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 74364C 89 APPLICATION FOR PERMIT LIME GREEN
01 hereby affirm that I have a certificate of consent to self insure,
or a Gertificate of Worlier''s Compensation Insurance, or a certified HEATING-VENTILATING AIR CONDITIONING
copy oarebf(Sec,3800 Lab.C.)
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 gDDRESS �� ��'
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY �'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST '
CERTIFICATE OF-EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be,completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100).or less.) AIR HANDLING UNIT,CFM
Dlsmlcr No. PROCESSED BY .
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU—
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE'TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU d D VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
FeAlcag0u
License Number Lic.Class
CL
Contractor Date C
I am exempt under Sec. Plan check fee Q
BAP.C.for this reason PERMIT ISSUING FEE$ C
Date: TOTAL FEE BD a
Signature PLAN CHECK APPLICANT d
OWNER-BUILDER DECLARATION
I'hereby affirm that I am exempt from the Contractor's License Law NAME
for the followingreason(Section 7031.5, Business and Professions , 4+
i
a): ADDRESS t�(1t.�
I, as owner of the property, or my employees with wages {o4
as their sole compensation, will do the work and the CITY TEL.NO. 330 3 i0
.0
structure is not Intended or offered for sale(Section 7044, ,x(. t
Business and Professions Code). WNER 1 ITEMS
❑ I, as'owner of the property, am exclusively contracting MAIL' —_
with licensed,contractors to construct the project (Sec- ADDRESS ` TOTAL►TAL .3--m 00
tion 7044,Business and Professions Code). CITY 16 -TEL.NOL% _J®® CHECK 31,013
CONSTRUCTION LENDING AGENCY 1 CHANGE r
I hereby affirm that there is a construction lending agency for CONTRACTOR Oil. 11
.011
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS �t
Lender's Name CITY TEL.NO. 01300-00131 3/14/91
L'ender's Address STATE LIC. 9 :19
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
Jantate I s relati to build' g construction,and hereby authorize
ent e s Co o enter upon the above-mentioned
1 s 0 es. SEE REVERSE FOR.EXPLANATORY LANGUAGE
E DATA E '