HomeMy Public PortalAbout9939 OLIVE ST_Mechanical__ -WOthatI COMPENSATION DECLARATION 7GA348DPW9/89 APPLICATION FOR PERMIT LI E GREEN
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I he0eby affirm that) have a certificate of consent to self insure,
or a certificatp,of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
rept(Sec.3800 Lab.C.)
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COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
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❑ Certified copy is hereby furnished.
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1IfA�� Certified copy is filed with the county building Inspection FOR APPLICANT T FILL IN BUILDING
ADDRESS C
ep rtment. s (PRINT OR TYPE ONLY)
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Applicarlt � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS (y�
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. / ��� � deet,_elC/
COMPRESSOR,BTU ,0490 • (e
APPROVALS DATE INSP R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH •z3
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: FAUVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU " Q VALIDATI N
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.
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License Numb eCj 7�? LID.Class
.-f 3303
ContP5ei61�Q"'-�' �� '
yea
atei ITEMS 0
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I am exempt under Sec.
Plan check fee TOTAL 126 e '
BAP.C.for this reason PERMIT ISSUING FEE 51) CHE K ii7L �
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Date: Liv
TOTAL FEE 4, 70 CHANGE o0�
Signature PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME 0000-0001 4/ $/965
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
5753 1 AM 7:56
I, as owner of the property, or my employees with wages
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 Z
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CI TEL.NO.
I hereby
eby affirm that there is a construction lending agency for
the performance of the work for which this permit Is CONTRALTO issued Poo. i
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name /fes�. Q
CITY y TEL.NO.
Lender's Address STA E / /J/J�j/ y LIC.
I certify that I have read this application and state that the above LICENSE NO mss- 7 !!G� 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
y property oinspe tion p rposes. r� SEE REVERSE FOR EXPLANATORY LANGUAGE
�TURE F APPLE OR AGENT DATE