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HomeMy Public PortalAbout4958 LOMA AVE_Mechanical__ WORKER;S COMPENSATION DECLARATION 200046 DPW 9/89 ��lo�fl �(�� 1T�®Ill I!—®� �L��Iltlll�� 76A364C I-'L� �e+ 11 - I hereby affirm that I have a certificate of consent to self Insure, et a certificate of Worker's Compensation Insurance, or,a certified HEATING- VENTILATING-AIR CONDITIONING copy thereof(Sec $800 Lab C) Policy�Jo; Company COUNTY OF LOS ANGELES = DEPT'OF PUBLIC WORKS BUILDING AND SAFETY DIV. . El, Certified copy is hereby furnished ❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING _ department' r (PRINT OR TYPE ONLY) ADDRESS •Qj I/I,(,p, ,����: Date- Applicant , LOCALITY,: NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTST , COMPENSATION INSURANCE CROSS O ABSORPTION UNIT,BTU ASSESSOR �('' ' (This section need not be completed if the work involved by the MAP BOOK ✓ PAGE �� PARCE 7 permit Is for one hundred'dollars($100)or less.) AIR HANDLING UNIT,•CFM ' DISTRICT NO, t . 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 BOIL"ER,BTU become subject to the Workers'Compensation Laws /� iS�Q � O COMPRESSOR,BTU /u'ee cq, O c� APPROVALS' `DATE INSPECT 'S SIGNATURE ' Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this"Certificate of ROUGH ' „ S Exemptiori,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL l provisions or this permit shall be deemed revoked FURNACE FAU GRAVI -y LICENSED CONTRACTORS DECLARATION FLOOR BTU D / O 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' License Number Lic Class e ACCT.g • �- Contractor Date'• c�Ci D 'M3 133.95 a- ❑ I am exempt under Sec Plan check fee 1 'ITEMS v B&P C for this reason PERMIT ISSUING FEE 7• �' TOTAL -9 F 4 - 95,0 Date TOTAL FEE CHECK 133.95 w SignatureCHANGE .r0 a OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z ` I hereby affirm that I am exempt from the Contractor's License Law NAME ;f yin�t't�1 t tftC� .for the following reason (Section 7031 5, Business and Professions `' `V 0UtJ1�—�rtrtfl S/ 1/96 Code) r, ADDRESS //_ IA t, n ❑ I, as owner of,the property, or my employees with wages L Il�V• C/ �7a,6j ' . l AN10.41 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) ' CONSTRUCTION LENDING AGENCY CITY TEL NO I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the,work for which this permit is issued CONTRA �GGLi (Sec 3097,Civ C) D ' F ADDRESS Lender's Name _ CITY TEL NO " Lender's Address STATE LIC I certify that I have read this applicatiori 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 pr ty or inspegtion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 1 PACAOR AGENT DATS