HomeMy Public PortalAbout5649 LOMA AVE_Mechanical__ VNORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 A
76A364C A
I heraby affirm+that I have a certificate of consent to self insure, PPLIC�4TION FOR PERMITI IME GREEN
„.
:ora certificate'of Worker's Compensation'Insurance, or a certified HEATING -VENTILATING-'AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) '
NoCOUNTY OFLOS
Policy
. Company ANGELES' DEPT OF P.UBLIC.WORKS BUILDING AND SAFETY DIV:
❑ ertified _ .
Ccopy is hereby furnished.
❑ n FOR APPLICANT TO FILL IN ABUIDD E G
Certified copy is filed with the county building inspection ADDRESS
department:,.: (PRINT OR TYPE ONLY)
LOCALITY (}
Date Applicant'
NO. 'TYPE OF APPLIANCE OR EQUIPMENT •FEE
• - - NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST., , ftu iz
COMPENSATION INSURANCE, ABSORPTION UNIT,BTU
;}(This section need riot be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued•, I shall not employ'any person in,any manner.so as to BOILER,BTU
%become subject to the Workers'Compensation Laws. �• 00 C�LL:�s
(,� Z COMPRESSOR,BTU
Date -I —[_L Applicant 1. - ��} �Cj^( � VENTILATION"SYSTEM APPROVALS DATE ws oas SIGNATURE---
-7-
TO APPLICANT: If,,after making this Certificate of..- ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply-with such. FINAL ,I
provisions or this permit shall,be deemed revoked'. FURNACE:, ':FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR -—BTU
' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 -• SUSPENDED UNIT
,(commencing with Section 7000) of Division 3 of the Business and HEATER: WA
Professions Code,and my license is in`full force and effect.
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License Number ' Lia Class _Z U y� •`���(J
kSA .
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('�t,nl - l- ;iVDa e4/t
Contractor z
❑ I am exempt under Sec. Plan*Check fee - O
B.&F.C.for this reason PERMIT ISSUING FEE
Date: �� -- I1 - UJ
Y+ Signature - - --« Cn
TOTAL FEE
i.',i .' s�O .31"t
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PLAN CHECK APPLICANT Z.i
OWNER-BUILDER DECLARATION I;rt` i11_
.I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031:51 Business and-Professions ., ® (�ILt.`'� l,f fl.• 1
..Code): -.;., - . ,: - ADDRESS ( i'�}=fI.9�
❑` 1, as-owner of the property, or my employees-with wages 'E' '}'I$jI
as their sole compensation,;will do the work -and the CITY TEL.NO.
structure'is.,notintencled or offered for sale (Section•7044;'
Business and Professions Code).. OWNER 1. I tl_EC S_a's f j! /`95
,
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❑ 1, as owner of the property,,am exclusively contracting r•D �-
• AIL f'M 443
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with licensed contractors,to construct the project (Sec-.'• ADDRESS.
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY f'?I jn 1, 'tA TEL.NO.
I hereby.affirm.that there is'a construction lending agency for
the performance-of the work for'which this.rpermlt Is Issued CONTRAC70R ) A7, ll r t"
C Vd 1 r V7✓//.' °
(Sec: 3097,Civ. C.)'
_ ADDRESS '
Lender's Name CITY (; SEL.NO.
It-40 \
Lender's Address STATE
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I certify that I have read this application and state that the above LICENSE NO. ,4,5 1 � � CLASS C
information is correct. I agree to comply'with all County ordinances
and State laws relating to building construction,and hereby authorise 4
representatives of this County to enter upon the above-mentioned
property for,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT - DATE - -