HomeMy Public PortalAbout5746 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION' 20-0046 DPW 9;89
76A364C .` APPLICATION POR-PERMIT LIME GK
EENI
I hereby affirm.that I have a certificate of consent to self,insure,
or a certHicate of.Worker's.Compensation' Insurance, o� a.certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.). `
Policy No. �4ft Co 'pan `rte` �y�-�' COUNTY OF LOS ANGELES, DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Ceftified copy is hereby fufnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN- poo E S
depa ment..
(PRINT ORTY.PE ONLY) /
Date v A licant LOCALITY_
pp NO. TYPE,OF APPLIANCE OR FEE
CERTIFICATE OF EXEMPTION FROM•WORKERS' . .` NEAREST
CROSS ST..
COMPENSATION INSURANCE, ABSORPTION UNIT,BTU '•
This.section need not be completed if the work involved.b ASSESSOR
( P Y.the � :, MAP BOOK � .PAGE ;;, PARCEL'
permit is for one hundred dollars($100)or less.) AIR HANDLING'UNIT,CFM "
_ DISTRICT NO. PROCESSED BY ,
I certify that'in the performance of the work'for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU ��
become subject to the Workers'Compensation Laws j
! COMPRESSOR,BTU L 8, (f f/V011
_ APPROVALS- DATE-'. INSPECT 'S SIGNATURE
Date Applicant VENTILATION SYSTEM r
NOTICE..TO APPLICANT: If, after making this,Certificate of ROUGH
Exempti ,you should become subject to the Workers'Compensation fi-1A
EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with-such ' FINAL Z(_C'
provisions or this permit shall be deemed'revoked. FURNACE:, AU GRAyJIY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 3 5' VALIDATION
I hereby affirm that l am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3-of the Business and: HEATER: WALL L`
Professions Code, and my license is in full force and effect. ACCT.
License Number 5 Ll � Lia Class ` �'3 / v I't 1, 6.336
1 ITLEMS
. ,
SIAII 7 Nle CPIV Date J' I •'l3
Contractor -
,l am exempt under Sec.
Plan,check f@2 �AL O
!
I
B.&P.C.for this reason `PERMIT ISSUING FEE$ - `K
i:` � 1�O" O
Dater „
�Ir�
TOTAL FEE
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Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT, 0000-1000 - �1,+h�l1i jf97 U)
I herebyaffirm that I am exempt from the Contractor's License Law „„ -sr1 1 I tjr'I�� -
for the following reason (Section 7031.5, Business and Professions NAME F% oK , `'c G /L?A J �, C� '
Code)
ADDRESS
I, as with wages
owner of the property; or my employees w
,
as their sole compensation; will do the work and the CITY •T + , TEL.NO.'
structure_is not intended or offered for sale_(Section 7044; s �L.-
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting
MAIL
with licensed contractors.to const(uct.the project (Sec- ADDRESS ' - -
tion 7044,Business and Professions Code): 7'
CONSTRUCTION LENDING AGENCY CITY TEL:NO. -
I hereby affirm.that there is a construction lending agency for _
the performance of the work for which this permit Is.issued CONTRACTOR, Sl /
(Sec. 3097, Civ..C.)..
ADDRESS,.J��3 /
L'ender's Namej] p
CITY W t-Al 07- TEL.NO %�7/1 S _
.Lender's Address STATE LIC. ^ �
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 Ccmy to enter upon the above-mentioned
property for i ectioA rposesr' SEE REVERSE FOR EXPLANATORY LANGUAGE.
SIGNATURE OF APPLtP,OC ENT DATE