HomeMy Public PortalAbout9935 OLIVE ST_Mechanical__ ION
aNOBKER'SCOMPENSATate of consent to 7�64DPW 9la9 APPLICATION FOR PERMIT LI E GREEN
I hereby affirfi that I'have a certificate of consent to self insure,
or a certificatenf Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
opywherepf(Sec.3800 Lab.C.) 04
b
ley No./
o�"��f'z G COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. G �r
Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
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Qr/ GC��j�y LOCALITY
Da A Iic n NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1 ��
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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 S j�
become subject to the Workers'Compensation Laws. (f
COMPRESSOR,BTU �' %O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after.making this Certificate of ROUGH Z
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 TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU i6 1 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license Is In full force and effect.
��f 7� LicG,
License Numbs .Class
ACCT.10 a
ntraDID Dat�' P JJO� 1�6■7
❑ I am exempt under SecPlan Check fee
.
I 1 ITEMS a
B.&P.C.for this reason PERMIT ISSUING FEE O TOTAL 1 o C
0
Date: TOTAL FEE CHECK 126.70 U
Signature11
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE ■OO L U,
I 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 0000-0001 4/ 8/96
I, as owner of the property, or my employees with wages 5755 t i AM 7:57
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
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS -�
tion 7044, Business and Professions Code).
C TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRALTO
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NOZS-.6_- b
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE N T ! 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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE