HomeMy Public PortalAbout5327 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89
76A364C 1�'110�
APCATION FOR PEWlltl T
76A3 -
I hereby affirm-that I have a certificate of consent to self insure,-
or a certificate of.Worker's Compensation Insurance, or a certified 'HEATING,-VENTILATING-AIR,CONDITIONING
UME-AREEN
copy thereof(Sec.3800 Lab C) U
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV:
❑ - Certified copy Is hereby furnished
'-Certified copy is fled with'INe county building inspectioh ' FOR APPLICANT TO FILL IN BUILDING
ADDRESS '✓��
•• department.' (PRINT OR TYPE ONLY) '
bate Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
• •CERTIFICATE OF EXEMPTION FROM WORKERS'.,, CROSS ST.
COMPENSATION;INSURANCE ABSORPTION UNIT,BTU' ASSESSOR
(This(This section need not be'completed.If the work,involved by the MAP BOOK '�� PAGE (• PARCEIeOZ
..permit Is for one hundred dollars($100)or less.). AIR HANDLING UNIT,CFM DisrRicr No PRocesseD By.
I certify that in the performance of the,work,for which this,;per '
Is issued, I shall not employ any person In any manner so a to BOILER,BTU
become subject to the,Workers'Com tion Laws.
COMPRESSOR,BTU '
.s' '- APPROVALS DATE INS OR'S IGNATIJRE
Date Applicant VENTILATION SYSTEM
NOTICE'kb A PLICANT: If, after ing this Certificat f ROUGH
Exemption,you should become subje to th Workers'Compensation EVAPORATIVE COOLER
• provisions of.the Labor Code, you s thwith,comply with such FINAL oew
provisions'or this permit shall,be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION. ,', FLOOR BTU ifALIDA'TION
I hereby affirm that I,am licensed under-prgLisions•of.Chapter 9 HEATER SUSPENDED_,U NIT
,(commencing with Section 7000) of Division 3 of the Business and ' WALL
Professions Code,and my license Is In full force and effect.'
' .--•GsC� 9 O
License Number �r-1 U Lic.Classes •� q
) D AGCTe
, OContractor -Arnn,om�..9 'Da
❑`
Plan check fee 3303
lam exempt under Sec 3fie4•
' -`..1 TTEMS- o
B&P.C.for this reason PERMIT-ISSUING FEE$ 7
/TOTAL, 36'_1• 50
Date: TOTAL FEE
Signature' ' :I, CHECK .36.4•c a.
a.
OWNER-BUILDER DECLARATION ", ,: PLAN CHECK APPLICANT CHANGE' 400Z_
I hereby affirm that I am exempt from-the Contractor's License Law NAME 4.n.
• forthe following reason (Section 7031.5, Business and Professions ii I t7t
Code): ADDRESS .¢-� . VIJUU—VL/U1 7! 1r1/70
❑,a I, as owner of the property, oi,"my employees,with wages l7 7 �/i! �1 r ,r,f
• as their'sole compensation, will do the wo'rk.,and the CITY GC TEL NO ,Z l'7 7431 1 All g-cfj
structure Is not Intended or offered'for sale (Section 7044, / ;
Busmess'and Professions Code). OWNER
❑.': I, as owner of the property, am exclusively contracting MAIL
withji6ensecl contractors'-to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).'
v CONSTRUCTION LENDING AGENCY , CITY, ^ /`-,l TEL NO
'I•hereby affirm that there is a construction lending agency for CONTRACTOR v
the,performance of the work for which thisfpermit Is issued T
(Sec.3097,Civ.C.)
ADDRESS L
Lender's Name t-
CITY L TEL.NO -2-17—[b - - -- - - -
r
Lender's Address STATE- LIC
I certify that I have read this application'and"state'that the above' LICENSE NO (1 CLASS
information is correct. I a dinto comply with all County ordinances
and State laws relating to g construction,and hereby authorize' „
fives of this C nty;to enter upon the above-mentioned
ert r i ction r e "
SEE REVERSE FOR EXPLANATORY LANGUAGE'
�7.60.PATURE APPLICANT NT DA , - - • - '. - _ -