The URL can be used to link to this page

Home My Public Portal About5521 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 - ��®�, ®.� PERMIT GRUEN 76A364C' tl� LI E I hereby affirm that I have a'certiticate of consent to`self Insure, or a certificate of Worker's Compensation Insurance, or a certified ( HEATING-VENTILATING'-AIR'CONDITIONING copy thereof(Sec 3800 Lab C) Policy No Company COUNTY OFILOS,ANGELES DEPT OFPUBLIC WORKS BUILDING AND'SAFETY DIV. Certified copy Is hereby furnished ❑ "r Certified copy Is filed with the county building-inspection FOR APPLICANT TO,FILL IN ADDRE S � department "." (PRINT OR TYPE ONLY) 'Date ` Applicant - ¢ LOCALITY 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,' ' permit Id for one hundred dollars($100)or less) AIR HANDLING UNIT,CFM DISTRICT NO " PROCESSED BY s,y •' I'certify that In the performance of the work for which this permit is Issued,,l shall not employ any person m any manner so-as to BOILER,BTU ; become subject to the Workers'Compensation Laws COMPRESSOR,BTU Ov©- O ' Date � ,4 IlCant a APPROVALS DATE INSPECTOR'S SIGNATURE PP VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH f -.'Exemption,'you should.become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked " FURNACE . FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION khereby afflrm,that,l,am,llcensed under provisions of,Chapter 9 SUSPENDED UNIT (commencing with Secti6n.,7000) of Division 3 of the Business and HEATER WALL �! Professions Code;and my license Is In full force and effect ; License Number Llc Class �� ContractorDate C) EY.• I am exempt under Sec Plan Check fee V • B&P C for this reason PERMIT ISSUING FEE$ 2 (0330 �,.30 0 Date TOTAL FEE - 1 ITEMS U W SI nature " n- PLAN CHECK APPLICANT Q w' �•••� g OWNER-BUILDER DECLARATION - ' (J /TOT[�AL- 1�-o'''.�§�3�`� Z I hereby affirm that I am exempt from the Contractor's License'Law NAME CASH 03,30 • -for the following reason (Section 7031 5, Business and Professions uAl�r Code) , ADDRESS CHANGE • .011 . ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and,the CITY TEL NO r�•�n fy�y�t 4/11/96 f 1 structure Is not Intended ot,'offered for sale (Section,7044, tR)�10-0001 7 11!96 Business and Professions Code) OWNER L ppMM 0n3 I, as owner of the property, am ezclusrvely contracting ,� � � ,, ' 5$�,? 1 � ,ftl �'U3 �' 'MAIL- with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code) _c.. _ CONSTRUCTION LENDING AGENCY CITY ' TEL NO -U7- /� i 1 I hereby affirm that there Is a construction lending agency for I performance of,the work for..whicfi'this permit Is Issued CONTRACTOR D (Sec 3097;Civ C) ' ADDRESS Lender's Name' CITY TEL NO Lender's Address I certify that I have read this application and state that'the above LICENSE NO CIAS_S t information Is correct I agree to comply with all County ordinances. 'i and State laws relating to building construction,and hereby authorize representatives of this'County to enter upon the above-mentioned prop ertys�pection pur oses , SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE 0F gppLICANT R AGENT _ n DATE � ,