HomeMy Public PortalAbout5705 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR PERMIT•',
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I hereby affirm tifat ],have a certificate of consent to self insure, ,
IME �u.E E W
or a`certificate of'Worker's Compensation Insurance, or a,certitied kEATI�IG-VENTILATING-:.AIR CGNDITIDNING
Copy thereof(S c.3800 Lab.C.)
Policy No. I"' Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKSBUILDING•AND SAFETY DIV.
Certified copy is hereby furnished.'
.Certified copy is filed with the.county building in ection FOR APPLICANT TO FILL IN'. BUILDS v
depa m t (PRINT OR TYPE ONLY)
Date —Applicant,' LOCALITY
r•
pp -� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
~ COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSSOR
'(This'section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.), AIR HANDLING UNIT,CFM
-- DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, [-shall.not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS •DATE. INSPECTOR'S SIGNATURE
DateApplicant " - VENTILATIO N SYSTEM -
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should-become subject to the,Workers'Compensation EVAPORATIVE COOLER r' Ct
'
provisions of the Labor Code, you must forthwith comply with such FINAL
-provisions or this permit shall be deemed revoked. FURNACE: FAU ' GRAVITY - - -
LICENSED CONTRACTORS DECLARATION FLOOR - BTU ? lv VALIDATION
I hereby,affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing.with Section 7000)of Division 3 of the Business and HEATER: WALL - -
Professions Code,and my license is in full force and effec
License Number Lic.'Cla s
Contractor' J
1t'/ Date 0
Plan check fee - U
;l am exem t under Sec.. 0
e.&P.C:for this reason PERMIT ISSUING FEE'$ F—
Date: - W
TOTAL FEE �, :( T_RT
CL
Signature,. _y I_r co
OWNER-BUILDER DECLARATION PLAN,CHECK APPLICANT T 1U�• y,l Z
I hereby affirm that I am exempt from the Contractor's License Law NAME k !T ENS,
for the following reason (Section 7031.5, Business and Professions '
Code j: f it
ADDRESS E ` 0
I,as owner of the property, or my employees with wages
as their sole compensation, will do the work.and the CITY TEL;NO. (-H { °L
structure isnot intended or offered for sale (Section 7044; / `�
Business and Professions Code): OWNER �y<___0
�y/ H6 ��L I E
I as owner of;the.property am exclusively contracting MAIL 1r cam=
with licensed contractors to construct the project (Sec=: ADDRESS 00i 1, 2 I3I
tion 7044, Business and Professions Code). Y.
CITY TEL.NO. "_15
1 • T` t _,
CONSTRUCTION LENDING.AGENCY y: n�c
I hereby affirm that there is a construction lending agency for CONTAACTOR
the,performance of the work for which this permit Is issued
(Sec:'3097,Civ. C.). j ,
ADDRESS h
Al
Lenders•Name
- .. CITY ! TEL.NOI` -
Lendei's'AddressLIC:
l-g
STATE .
- 'I:certify that I,have read this application and state that the above LICENSE NO. CLASS
information is correc I agree to comply with all County ordinances _.
and State laws rel i to building construction,and hereby authorize
rppresent es t i County to enter upon the above-mentioned
property in cti rpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATU E A PLICA AG N "'