HomeMy Public PortalAbout9933 OLIVE ST_Mechanical__ ION
WORKER have aENSATate of consent to 20-0046 DPW APPLICATION FOR PERMIT UME
I hereby,affit'm that I have a certificate of consent to self insure, GREREIN
or 8 certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
�cc y thereof.(Sec.3800'Lab.C.)
/p"oiicy off. ��'2�Co`mmppa � 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 BDDRE S
UILDING
dapJQ�rt-ment) / (PRINT OR TYPE ONLY) /
It y" /1ifr' -Applicant �aB NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
NEAREST �yV
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
OR
(This section need not be completed if the work involved by the MAP OOK PAGE =PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCF,SSED BY
I certify that in the performance of the work for which this permit G(/�
is issued, I shall not employ any person in any manner so as to BOILER,BTU—
become
TU become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER _
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. / FURNACE: FAU JTY — VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU !i'(%!i' (i fe G,
1 hereby affirm that I am licensed under provisions of Chapter 8 SUSPENDED UNIT
l!_
(commencing with Section 7000)of Division 3 of the Business and HEATEWALL
Professions Code,and my license is in full force and effect.
License Nun4 er'(/ " 7 Lic.Class G Z
/ > ® L8r I
o- ct
❑ Plan check fee ACCT.
I am exempt under Sec. -,
B.&P.C.for this reason PERMIT ISSUING FEE$ ,f) 3303 126.70
Date: TOTAL FEE 1 ITEMS I
/ � D I
Signature
TOTAL J 2 6 o 7d,OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK2
16.76
I hereby affirm that I am exempt from the Contractor's License Law NAME ® CHANGE I][�
for the following reason(Section 7031.5, Business and Professions
Coe): ADDRESS
1, as owner of the property, or my employees with wages VVtrV—Ol [)i1 4/ 8/96
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, ���
Business and Professions Code). OWNER
1 AM 7 56
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
hI hereby affirm that there is a construction lending agency for CONTRACTO
t :,performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS ✓�-
Lender's Name
CITY EL.
Lender's Address STATE 9= 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
representatives of this County to enter upon the above-mentioned
property o inspec n purr os � fG SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA LICANT OR AGENT DATE