HomeMy Public PortalAbout5527 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89:`
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I hereby affirm that.I'have a'certificate of consent to self insure, `
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,PPLICATI'ON F®F$:P'ERi0J
or a cer'*c%t to O_•Workers;Compensation Insurance,'or a certified. : n. 1. ,
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copy thereof(Sec:3800 Lab.C:)• EN ON 41T 0
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HEATING ''V-'VENTILATING-.;AIR.. I NG`
Policy,No.' Company 'COUNTY:OF,LOS.ANGELES DEPT OF PUBLIC WORKS ° BUILDING AND SAFETY DIV ,
❑ Certified copy:is hereby;fu`rnlshed
:x' BUILDING;. ` .
Cerffied copy is filed with the county bulldmg inspection . FOR'APPLICANT'TOLFILL'IN'
;> department•'' " , i
.•',.(PRINT OR,TYPEON Y) .t. c �C17� �
ADDRESS J �7 i
PP NO. TYPE
„Date A licant' CALIITY r/I
- t, .. ;, . .. OF;.AP-PLIANCE OR EQUIPMENT `.FEE
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'^CERTIFICATE:OF•EXEMPTION FROM WORKERS'• :x NEAREST.
.COMPENSATION INSURANCE Qt 11
X ABSORPTION UNIT,BTU
CROSS;ST Q
(This section need not be completed:if„the work involved by;the MAP BOOKt PAGE PARCEL
permit,is for one hundred dollars($100):or less.). AIR HANDLING-UNIT,CFM DISTRICT No: 'PROCESSED.BY
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('certify chat in the performance of the^-work foc,which this.permit: ",• ; ` c
P y Y P n . Y, o as to BOILER,BTU ,.
Is.Issued,•I shalLnot em to an arson In an manner s
become subfect to the•Workers Compensation Laws
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-, • ”, COMPRESSOR BTU' >
:; „',. -. "r•_• APPROVALS,' DATE INSPECTOR S'SIGNATURE
Date Ap Ilcant
' ... -, .P ,-- ,-: -- ' �.:�. VENTILATION SYSTEM
NOTICCTO APPLICANT:.If„after making this Certificater'oP ROUGH
Exemption,'you should.6ec6me subject,ltd.the,Workers'-Compensation ? EVAPORATIVE COOLER
provisions•of the Labor,Code, you must forthwith comply with such' FINAL
provisions-orthis petmit shall'be deemed revokee. FURNACE. • FAU GRA ITY y'
LICENSED CONTRACTORS DECLARATION' / F,LOOR"" BTU OD " VALIDAT,ION t
'I hereby affirm that I am licensed under provisions.of,Chapter 9 SUSPENDED DNIT
.'(co-i:n ng with Section 7000) of Division 3'of.the Business and HEATER:_ WALL
Professlons'Code and"m"y license Is in full force and effect. M1
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License Number LIc.Class-
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Contractor Date
0• I am.exempt.under Sec.
Plan check fee,
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B.&P.0 for this reason .P r
ERMIT ISSWING`FEE$
Date:.
TOTAL.:FEE'
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Signature c
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,•• ^, - PLAN CHECK APPLICANT
•OWNER=BUILDER DECLARATION.- i
I hereby affirm that I am.exempt from theiContractor's License Law NAME k
for'th@-following:reason':(Section'7031:5, Business and,ProfessionsPP
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•. �.. '`-. ADDRESS,,"
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I as oviner of the',ptoperty, or my employees with,wages
:as'thelr sole compensation, will do the workand the CITY TEL:NO Y y z s y,i
structure'is riot'intended or offered for,sale (Section 7044, `.
Business and'•P,.rcfessionsCode) OWNER
l-, a's owner of.the poperty,'am`exclusively contracting MAIL
, (
- 4 P 1 (
ADDRESS"' - ,
WitF licensed contractors to.construct the, ro act Sec-
ode
tion.7044,,Busines's,and,Professions Code).
•. « - CITY" TEL NO '+ a •-�
CONSTRUCTION LENDING:AGENCY ` n L s
u�r z s.rat�F-
' (.hereby-affirm that there is a construction lending agency for CONTRACTOR
tFie°pern
formace"of the work for;which this.permit.is,=issued "f
,(Sec. 3097,Civ C,). ® a
r, •s ADDRESS
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Lenders Name F`I
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'- CITY.' TEL.NO, +,.
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Lender's'Address T
.: S ATE.' . LIC. 3 '
I cortify that I have read,this-applicatiomand state that the above: ,LICENSE NO: CLASS
information!is correct.'I agree.fo comply.with alt County ordinances
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and State laws.relating to building construction;and hereby authorize
re resentatives of this Count to;enter'u on the.abo"
p y p ve-mentioned :L
pro for inspection purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE ,Y
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SIGF APPLICANT OR AGENT. - `'DATE • •' ¢