HomeMy Public PortalAbout5936 LOMA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
•I hereby affirm that.I have a certificatf. of consent'to self I
in"gjre, or a certificate of\Vorkers' Comperisotiarr-lnsyronce,• HEATING - VENTILATING - AIR CONDITIONING
or a certif�d•copy'4hereof (Sec. 3860, Lab C ) 76A364C
20-0046 DPW!9/88
Polrcy NoJACO u%�'Company
❑ drtified copy is hereby furni"shed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy`is filed with the county building inspecFOR APPLICANT TO FILL IN BUILDING
-tion department., ADDRESS C'� s•-'-V
///%JJJ►►► - (PRINT OR TYPE ONLY) _
Date ` r Applicant , LOCALITY
NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST
"
-COMPENSATION INSURA CE CROSS ST. 1J7IJ,
(This section'need.not be completed if the work involved by ABSORPTION UNIT,'BTU DISTRICT NO. PROCE D BY
the permit is for one hundred dollars ($100) or less.)
AIR-HANDLING UNIT, CFM
I certify that in the performance of the work for which this 0,
permit is issued, I shall'not employ any person in any manner
BOILER,,BTU
-
,so as to become subject to the Workers'.Compensation Laws. aPPRovnis ATE ECTOR'S SiG ATURE'
0U9
Date Applicant COMPRESSOR, BTU. ROUGH
NOTICE TO APPLICANT: If, after.'making.this Certificate of VENTILATION SYSTEM FINAL . ' Z4M ,Exemption, you should become, subject to the Workers'Compensation provisions of the Labor Code, you must forth-s EVAPORATIVE COOLER AT
with comply with such Provisions or this permit shall be' deem-
ed-revoked. FURNACE: FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION - FLOOR . BT c' • 00, _
1 hereby affirm that I am licensed Under,provisions of Chapter 9 HEATER: SUSPENDED-1UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
6
License Number V5 Lic. Class O
oil-
Contractor Date O
❑ I'am'exempt u, er Sec. V
Plan check fee LU
B.&P.0 for this reason. h
PERMIT ISSUING FEE $ Z
Date:. OTAL F _
Signature TEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Low f6r the following reason (Section 7031.5, Business and NAME ,
Professions Code): _
I, as owner of the property, or my employees 'with ADDRESS
wages as their sole compensation, will do the work and t' ' =4
CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). .
❑ OWNER t:,�•
I, as owner of the property, am exclusively,contracting MAIL 1 1 ENS
with licensed contractors to construct the project (Sec-
ADDRESS "r"'' a
cion 7044, Business and Professions Code). .i +;;{)_ . - �03•m
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for A 'f y/ CHB--K 10 i Fil
the performance of•the work for which this permit'is issued CONTRACTOR ��fJ/ �9 [ ® '• H �{� )�
(Sec. 3097, Civ. C.).
r .
ADDRESS
Lender's Name'
v f tit; l
CITY U S �i TEL. NO. till 11{—'+._{LIU 3 tt ty:
t�
Lender's Address _
I certifyThat I' have read this application and state that the STATE L/' � — LIC. _ 26 15
t )I�j�:jll
PP LICENSE'NO. l oy CLASS
above information is correct. I agree to comply with.all County
ordinances and State laws relating to building construction,
and reby'authorize representatives of this County to enter
up n he ab v - ntioned property for.inspection purposes:
` , � ,SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of A cant or Agent Date