HomeMy Public PortalAbout5743 LOMA AVE_Mechanical__ • y A,4KER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
I hereby affirm that I have a certificate of consent to self insure, APPLICATION FOR PERMIT
76A364C LIME GREEN
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 OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADD BUILES 3-7V-3 /V. 2_01VA 4VZ-
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the MAP ASSEBOOK PAGE PARCEL
SOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit 01
is issued, I shall not employ any person in any manner so as to BOILER,BTU �� y P
become subject to the Workers'Compensation Laws. 0
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GR ITY
LICENSED CONTRACTORS DECLARATION FL6gR AL BTU 0" VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and TER:
Professions Code,and my license is in full force and effect.
License Number Lic.Class
a
Contractor Date O
ElI am exempt under Sec. Plan Check fee
A •�•- L a:B.&P.C.for this reason PERMIT ISSUING FEE$ '-"` ' ° 0
_�
Date: TOTAL FEE ;-'
Signature �� __E a
W
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT i l;A 37 = 00 Z
I hereby affirm that I am exempt from the Contractor's License Law NAMECo , CH
r•'; ;7 I
fforr�the following reason (Section 7031.5, Business and Professions +-HEC*K -* .Orl
e)' ADDRESS a %��n AA f �-'':=.A it a ht s
I, as owner of the property, or my employees with wages �� `� r �--1J��7 �� _l"Irf�It7i_
as their sole compensation, will do the work and the CITY T�l�J r C?i7V TEL.NO. it—�C'f
structure is not intended or offered for sale (Section 7044, G[Z 4 O O 00"t E—t ra t' _' ' 'C +
Business and Professions Code). OWNER � 'l[�.G _ OLIUi Li; _I, +`_
❑ 1, as owner of the property, am exclusively contracting 7qq
MAIL pp,,`F 4,,!; 1
with licensed contractors to construct the project (Sec- ADDRESS ���Ly /� 1-011(,4 Av&
tion 7044, Business and Professions Code). CITY T C/7-if TEL.NO.
CONSTRUCTION LENDING AGENCY °�C:
Ihereby affirm that there is a construction lending agency for CONTRACTOR L Poo.the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro a ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE