HomeMy Public PortalAbout5346 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION e o763346 DPW 9/89 MA PPUCATMW FOR PERMT LUAF
� ���
I hereby affirm that I have a certlffctitf consent to self Insure
, 76A364C �7
or a certificate of Worker's Compensation Insurance, or a certified '' -'HEATING-VENTILATING-AIR CONDITIONING '
copy thereof(Sec 800 La C) L
Policy No Company COUNTY OF LOS ANGELESWIIDEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
FCertified copy Is hereby furnished
BUILDING
❑ C rtifi d copy Is filed with the county building in tion FOR APPLICANT TO FILL IN ADDRESS,
pa t (PRINT OR TYPE ONLY)
LOCALITY VV
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed,if the work Involved by the MAP BOOK PAGE PARCEL^.
,perm it
Is for one hundred dollars($100)or less.) _ AIR HANDLING UNIT,CFM ' -
DISTRICT NO PROCESSE V
I certay•that In the performance of,the work for which this permit
Is Issued, I shall not employ any.person In any manner so as to BOILER,BTU h�1y
become subject to the Workers'Compensation Laws , 5-V V
' • • t I 'COMPRESSOR,BTU
Date Applicant ' VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT If, after,making this Certificate of ROUGH '
Exemption,you should become subject to the Workers'Compensation '''
EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such _ FINAL
,provisions or this permit shall be deemed revoked FURNACE FAU G AVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU �Ql`7 VALIDATION
I hereby affirm that I am licensed under, provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and 'HEATER WALL
Professions Code,and my license full force and effect
License Num er Llc Class 1
Contractor Date �^{
❑ I am exempt under Sec Plan Check fee
e&P C for this'reason PERMIT ISSUING FEE$ 2� 3� O
.,
DateW
TOTAL FEE
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt,from the Contractor's License Law NAME it i D t--�^VAmmBOQ7C fc�Owl
f r the following reason (Section,7031 5, Business and Professions L_o___.�9tWwa0i7a, '21rSV�lJ
Ua's
ADDRESSasowner of the property,-or my employees with wages
their sole compensation, will do the work and the CITY TEL NO ✓ 6� G` /
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 r
e
' tion 7044, Business and Professions Code) 1 0u�
CONSTRUCTION LENDING AGENCY CITY j/ EL N r
I hereby affirm that there Is a cons6uctipn lending agency,for CONTRACTOR D
the performance of the work_ for which'this permit Is Issued
AM J
(Sec 3097,Civ•C)
ADDRESS
Lender's Name
cily� ,� D TEL NO '
Lender's Address a•
ENCL
I certify that I have read this application and state that the above SE NO
LICASS
Information Is correct I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authors
reprgfpentatives of this County to enter upon t e ab ve-me ned
pro rty for inspec to urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
TU E OF A ICAN GENT DATE '