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HomeMy Public PortalAbout4967 LOMA AVE_Mechanical__ WORKERS'COMPEL: NSATION DCL.ARATION 76a36aC I hereby affirm that I have a certificate of corisi�nt t t E 8,8 ('p an, APPLICATION FOR PERMIT insure,certified a certificate ytheof((Sec. 38 0,Compensation I,s,:ran, l HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec, 3800, Lab. C.) �• V Policy No. - Company a Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection BUILDING �,; 1 e deflertment: ._ FOR APPLICANT TO FILL IN ADDRESS t w (PRINT OR TYPE ONLY) Date Applicant - - - ----- - — - ! } 1 TYPE APPLIANCE OR EQUIPMENT FEE LOCALITY, Y fi, t o CERTIFICATE OF EXEMPTION I ROM W.ORKLRS' - U — NEAREST COMPENSATION INSLIRANCI:: >✓ t •^ (This section need not be completed if the work involved - CROSS ST. ti �' "' �1 ._,'.{ J b the permit is. for one hundred dollars SI00) or less.) y p ( - DISTRICT NO PR OC ESSf D!' ,Y t r LL -^'•� I certify that in the performance of the work for .%hich this permit is issued. I shall not employ any person in any manner "'' cc' so as to become subject to the Worker' Compensation Laws. Jit F,'+ 'ITC -- - s.,f APPROVALS DATE INSPECTOR'S SIGNATURE QCC 'r DatePPiicant -- Mr Rr IS 5, T',;. r NOTICI TO APPLICANT: If, after making thi Certificate of -- ROUGH „ �U r'r _-. ___. -- FINAL LU # F.ICetnpt3©n, you should become subject to the Wor4.crs W CIy pens tion provisions of the Labor Code, you nrnst f, rth f with,comply.with such prdvisions or this permrt shill be } deemed revo>tdd. VALIDATI,`'`� LICENSED CONTRACTORS DECLARATION i,4reby aff�trt that I am licensed under provisions of Chapter A71 ER. SUSPENDLD UNIT 9 (commentlog with Section 7000) of Division 3 of the Busi WALL ° ness 4nd Professiops Code,°and my license is in full force and - efect ' E ' IuV�I3�9t ! License Number Lic.Class6 o 1 t l r ^ -- i � Contractor _ - --- ---- _ L_.L I am exempt from the licensing requirements as I am a *' licensed architect or a registered professional engineer P{ail Check fee ZJ% Of above. acting in my professional capacity (Section 7051, Bus- iness and us-inessand Professions Code). PERMIT ISSUING FEE $ '0 Lic.or Reg.No. Date---.-__ __ TOTAL FEE � HOME OWNER-BUILDER DECLARATION PLAN CHECK APPL!Ca.NT I hereby affirm that .l am 'exempt" from the C'ontractor's NAME ' C, s)� '`� ' �••` t r License Law for the following reason (Section 7.031.5, Busi- nessand Professions Code): ADDRESS 1, as owner'of the property, will do the s •tork and tl� � s structure i_ n6t intended' or offered for sale (Section CITY , TFL. NO. 7044, Business and Professions Code). •• H OWNER1 `U +1 aI, as owner of the property, am exclusively contracting with licensed contractors to constructthe project MAIL (Section'7044, Business and Professions Code). ADDRESS *,-)-r � CITY ,,, w ! t, f;��TEL.NO. b CONSTRUCTION LENI_)ING AGENCY �" _�" I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR r r"•' 1 f.t t.�'V, issued(Sec. 3097,Civ.C.). Lender's Name ----------._-.-- ADDRESS -• S_..�.' ,i '�, },1' z. .. -. Lender's Address - -- - C 1 f / :" ) r o '7 J ) i h s-!;T• . N O. f t. _ S" 7 t I certify that 1 have read this applicaron and tc Mat J,e STATE - - +. ``- y - LIC. above information is correct.I agree to C,nnpk o uh ;ll CmlwLICENSE NC. � D � `t' CLASS ordinances and State laws regulatin.g Hcatioe. Arrtilarin, .:nd Air Conditioning, and hereby authori e Ihi., y; , Irl .. PC`R !-'I\Ill NAIY)R5 LANGUAGE County to entIer upon thy-J abovc-n,,,n;iuued I",'.I,crr inspection r Ill p sesf --- -- -- - Signature of Permittee Dai- I