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Home My Public Portal About4964 LOMA AVE_Mechanical__ 'WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89APPUCATM^n�II` ®R 76A364C Y' •,• 4 r _ ,," ,� �"'.J LI U-„ I hereby affirm that I have a'certificate of consent to self Insure; or a certifi`cate'ofiWorker's Compensation Insurance, or a certified 'HEATING•--VENTILATING%AIR CONDITIONING copy`therebf(Sec 3800 Lab C) ®cy'No Company COUNTY OF LOS ANGELES -DEPT OF'PUBLIC,WORKS BUILDING AND SAFETY DIV. ed Certified copy-is hereby,furhlsh ' BUILDING Certif ed copjid'filed with the county building Inspection FOR APPLICANT TO FILL•IN ADDRESS �+�C7 L fl�,lJ�'' de part t ',d •• (PRINT OR TYPE ONLY)• p °b` fs` ' �i�Y s ' Date Applicant ((,u1( LOCALITY �^' T NO 'TYPE SOF APPLIANCE OR EQUIPMENT } FEE '' ` •, CERTIFICATE,OEXEMPTION'FROM WORKERS' NEAREST _ CROSS ST• COF P„ENSATION,INSURANCE ABSORPTION UNIT,BTU ASSESSOR' •(This,section need"not be`corripleted,If the work Involved by theMAP BOOK PAGE PARCEL, • 'permit Is,for one'hundred dollars($100)or less.), „'AIR HANDLING'UNIT,CFM ' A%r, ' DISTRICT NO - PROCESSED BY I certify that'in the performance of,1the work for which this permit Is Issued, I shall not employ any^person In any manner,so as toBOILER,BTU- become subject to the WOrkeFs' Compensation Laws J �/ (' COMPRESSOR,BTU O APPROVALS DATE INSPECT _ 'SIGNATURE •Date Applicant VENTILATION SYSTEM - '' _ ''° '�• v NOTICE TO APPLICANT If, after making this Certificate of' ROUGH ; Exemption,you should become,subject to the Workers'Compensation 3 ' EVAPORATIVE COOLER a° FINAL provisions of the Labo-r Code; you must forthwith comply with such provisions or this'permit,shall+be deemed revoked ' ',FURNACE -FAU GRAVITY,- c, 'LICENSED CONTRACTORS DECLARATION, - / FLOOR BTU w O ALI ATION' • I,hereby•affirm that I am,licensedunderprovisions of,Chapter 9 HEATER - SUSPENDED UNIT'* (commenting with Sectiori 7000) of Division 3 of the'8usiness and WALL Professions'Code,and my license Is in,full force and effect License Number Lic Class ContractoF �`�l/�� /.LIW c e ❑ Plan-check fee ♦. .1, -exempt under Sec a ACCT ACCT..r B'&PC for this reason' " PERMIT ISSUING"FEE.$ 0 :' - 3 Date ' TOTAL FEE" �.� �� -� ITEMS W T- - - a Signature _ OWNER-BUILDER bECLARATION PLAN CHECK APPLICANT TOTAL a• �� Z �o' _CHECK {{ `.Z I hereby affirm that I am exempt from the Contractor's License Law NAME 4FtE��t '•�14•S� 'for the'following reason (Section 7031 5, Business and Professions ❑ ) ,• CHANGE Code ADDRESS t 3' °VU 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,- ��}}{� //•�� / t - `Business and,Professions Code) `'-, OWNER �Ai J�e " .' ' f � ' 011 as owner of,the property, am exclusively contracting MAIL RaU ff with Iloensed contractors to construct the'project (Sec- ADDRESS,,, C tion 7044, Business and Professions Code) CITY TEL , .CONSTRUCTION LENDING AGENCY �� ` r,- I hereby affirm that there Is a construction lending agency'for` t, the performance.,of the work for which this per is issued CONTRACTOR „ (Sec 3097,Civ C) Yom" i lV h!A ADDRESS Lender's Name tt •� t _ CITY /t , TEL NO' 4K0 '014'a% .• ' Lender's Address STATE ,' LIC I certrfy that I have read this•'apphcation and state that the above LICENSE NO ty CLASS •G'— �Z Information Is correct I agree to comply with all County ordinances ` And State laws relating to building construction,and hereby authorize r y representat s of this County to enter upon the above-mentioned propert or inspection pu see SEE REVERSE FOR EXPLANATORY,LANGUAGE > " . < „ IONATURE OF APP NT OR AOE4r DATE " 'WORK RS'COMPENSATION DECLARATION 76-364[ y� pp ,,��•►► ��pp FOR �y(� (�/� I.hereby. affrm that I have b certificate of consent to self CE-818 (2-80) ,, �"� Li e 8`L �' ®0 Cl ®If�S If— lG YVti �� ;insGt.p .»ta}_ertificateofWorkers'Compensation Insurance,of HEATING.VENT ILATING.AlR CONDITIONING a certifie,cony thereof(Sec. 3800,Lah.,C•) a Poli yio-ll.%�j`1 ompany �� COUNTY OF LOS ANGELES Cer:itied copy is hereby furnished. BUILDING ARID SAFETY . Certified copy_is filed with the cou-ty building inspection BUILDING ❑ FOR APPLICANT TO FILL IN deyp�artment / ADDRESS r� DateJ'r�y fApphcant_�• (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST �>� �i�d a (This section need not be completed if the work involved ABSQRPTION UNIT, BTU CROSS ST O -by the permit is for one hundred dollars ($100) oI ILSs.) DISTRICT NO PROC ED BY V I certify that in the performance-of the work for which this AIR HANDLING UNIT,CFM ✓^' fy permit is issuea,_I shall not employ any person in any manner G✓, �/ - 0 so as to become subject to the Workers' Compensation Laws .BOILER BTU APPROVALS DATE INSPECTOR'S'SIGNATURE IU Date Applicant COMPRESSOR, BTU ROUGH d _ NOTICE TO APPLICANT. If, after making this Certificate of VENTILATION SYSTEM z FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY— LICENSED RAVITY LICENSED CONTRACTORS DECLARATION BTU (•� I hereby affirm that,I am hcenged under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing with Section 7000),f Division`3 of the Busi- ness and Professions Code, and my license is in full force and 0. effect., License Number /L/ic-Class Contractor�(V C�7��vDate ��y�� - �� I am exempt from the licensing requirements as I am a licensed architect or a.registered professional engineer' Plan Check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and,Professions Code).- Lic.or Reg.No. Date TOTAL FEE Q HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 13 I hereby affirm that I am exempt ,from- the Contractor's NAME w�.�re4 PcenACCTA se Law for the following reason (Section 703.1 5, Busi- ness and Professions Code • ADDRESS 3347 30.%. l ❑ I, as owner'of the property,-will do'the work and theITEM structure is not intended or offered fur sale (Section CITY' TEL NO 1 ' 3 ,,,y77A' t� 7044, Business and Professions Code). - OWNER //s, ` TOTAL 30 m -J+� ❑ I, as owner of the property, am exclusively contractingY�� with licensed contractors to construct the project MAIL Y , My, 3404 (Section 7044, Business and Professions Code). ADDRESS 1420 TEL.NO. ^uw; r 1 f 4Rt•NIZ CITY o ' CONSTRUCTION LENDING AGENCY -�tC—��ji��/ �o��Q j�• ` I hereby affirm that there is a construction lending agency .for the performance of the work ,for which this permit is CONTRACTOR " issued (Sec 3097,Civ.C) 10-000-0041 8/24/89 Lender's Name ADDRESS ,y7i AM po�a Lender's Address CITY TEL NO G i` t7 7 I certify that I have read this application and state that the STATE LIC• above information is correct I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating, Ventilating and -Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to nter upon the above-mentioned property for inspection Purposes ature of Permittee Date