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Home My Public Portal About4979 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 4DPW9/89 76A36 ��®� ®� �� UME , GREEN • 76A364C `s I•herety�affirm that I have a certificate of consent to self Insure, or a cerhflcate,'of Worker's Compensafion'Insurance, or a certified !';HEATING-VENTILATING-AIR CONDITIONING cbpy thereof SS:c 00033120• Policy No ' Company "COUNTY OF LOS ANGELES', DEPT OF PUBLIC WORKS BUILDING AND SAFETY,DIV. ertrfied copy is hereby furnished ❑ Certified copy is flied with the county building Inspection FOR APPLICANT TO FILL IN BUILDING Lot - department _ (PRINT OR TYPE ONLY) ADDRESS Date J-11 '9'11 ApplicantPXA, 167 LOCALI NO TYPE OF APPLIANCE OR EQUIPMENT FEE III - , t CERTIFICATE OF EXEMPTION FROM RKERS' NEAREST CROSS COMPENSATION INSURANCE Y ABSORPTION UNIT,BTU ASSESSOR ' (This section need not be completed:rf the work involved by the MAP BOOK PAGE PARCEL pe6r it is for.one hundred dollars($100)or less.)- AIR HANDLING UNIT„CFM DISTRICT NO PROCESSED BY I certify that.in,the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation Laws COMPRESSOR,BTU o©0 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this'Certificate of ROUGH — ” Exemption,you should-become subject to the Workers' Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION' FLOOR, BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is In full force and effect 99// tt •. ' !/til �fl U a LicenseNumber��JLic Class C—ZO Contractor Rd, 'Date —7 D a "❑ ec Plan check fee Q I am exempt under S " B&P C for this reason PERMIT ISSUING FEE$ DateTOTAL FEE _ e,U W Signature PLAN CHECK APPLICANT a J OWNER-BUILDER DECLARATION r Z Z I hereby affirm that I am exempt from the Contractor's License Law NAME D LJ for the following reason,(Section 7031 5, Business and'Professions- Code) ADDRESS �•`'• ACCT.8 • I; as owner of the property;or my employees with wages I °I as their-sole compensation, will do the work and the CITY TEL NO structure is-'not Intended or offered for sale (Section 7044', i ITEMS Business and Professions Code) OWNER q^� ❑ 1, as owner of the'property, am _exclusively contracting TO Al t 57 0 0 MAIL with licensed contractors to construct the project (Sec- ADDRESS 4979 Oka 57. i tion 7044, Business and Professions Code) `"HLC {°_1'j CONSTRUCTION LENDING AGENCY CITY TEL NO ��}�{f]C 1 hereby affirm that there is a construction lending agency for, CONTRACTOR •J D hI the performance'of the work for which this permit iB'Issued (Sec 3097,Civ C) An d 1 i _ ADDRESS LI�I00—.ODD f.!1 1;7'' 1 Lender's Name / { CITY (V/� Li= TEL NO _5T c— r: its 1 AM 9-" Lender's Address ` STATE LIC I certify that I have read this application 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 ppperty for inspection rposes SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APP CANT OR AGE DATE