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HomeMy Public PortalAbout5417 LOMA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT ' 1 hereby affirm that I have a certificate of consent to self in,fte, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab,. C.) 76A364C Policy N)�/f�+ �mpany F� ,pAjT 1,Vrtr,0 046 DPW 9/88 C'ertPfred copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy'is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS , L 0�[� lQ• (PRINT OR TYPE ONLY) Date Z_HApplicwt LOCALITY f 6/% Z6 4i/z NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION F ORK S' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. !C�BY ESSED the permit is for one hundred dollars ($100) or less.) .I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM Z 09 4_C" permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS • DATE NSPECTOR'S SI NATURE Date, Applicant COMPRESSOR, BTU 4LZ2 d 6O Qa ROUGH wl NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAUG VITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 4 0 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business HEATER: WALL. and Professions Code,and my license is in full force and effect. License Number j"oSS6$ Lic. Class d ezo } U Nip. U Contractor0'.4/A-i�ONPlLy✓ Z-2 -Q( O ❑ I am exempt under Sec. Plan check feeLU u B.BP.C. for this reason. PERMIT ISSUING FEE H $ v Date: Z Signatu TOTAL FEE WNER-BUILDER DE ARATION PLAN CHECK APPLICANT I hereby affirm that xempt am the.Contractor's License ► Law for the following reas ection 7031.5, Business and NAME Professions Code): rLs I, as owner of the property, or my employees with ADDRESS /� 8 wages as their sole compensation,will do the work and Ai.CT.T the structure isnot intended or offered for sale(Section CITY TEL. NO. 3307 47.5 7044, Business and Professions Code). OWNER "7'' ('j`C JVtc y F-1I I, as owner of the property, am exclusively contracting ✓ 1 ITEMS with licensed contractors to construct the project (Sec- MAIL o � tion 7044, Business and Professions Code). ADDRESS Lr A'✓ 'TOTAL 47-50 CONSTRUCTION LENDING AGENCY CITY �4'"( LF c!T TEL. NO. CHE47.!K1I hereby affirm.that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR ("j��Al el (Sec. 3097, Civ. C.). ,L/[ ADDRESS IJ rT T Lender's Name q 7 2 �y {'may � y / CITY �' �h7�I�� TEL. NOW�_r72—,9? DIDDO—WO 9!26/89 Lender's Address I certify that I have read this application and state that the LICENSE NO. �d S'S�S CLASS e 58096 1 AM10:20 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby put rize representatives of this County to enter upon the oned property for inspection purposes. "� SEE REVERSE FOR EXPLANATORY LANGUAGE ture Signaof Applicant Agent Date ©s