HomeMy Public PortalAbout6156 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 n �T p� �p '
,76A364C �"PPI!_�CA �®IICI ORPERNH T LIME , REEK:1,' '
I hereby affirm that I have a certificate of,consent to self Insure,
or•a certificate of Worker's Compensation,lrisurance, or a certified V :HEATING-VENTILATING,-AIR CONDITIONING .;
copy thereo S 3800 Lab ) IJ
Policy NoL�lornpany: COUNTY OF,LOS ANGELES. DEPT OF»PUBLIC WORKS BUILDING AND SAFETY DIV'
❑ Certified copy is hereby furnished.' $
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Certified copy Is filed with the,ou il mg Inspection' ' FOR APPLICANT TO-FILL IN r BUILDING
..departm nt. (PRINT OR TYPE ONLY) ADDRESS s' Lo
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"Date34 LOCALITY
Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT. -- FEE'
CERTIFICATE OF EXEMPTION,FROM WORK NEAREST. .
_ `
COMPENSATION INSURANCE CROSSST.
UNIT,BTU
(This section need,not be completed if the work involved by the, ASSESSOR-
permit
i , -
S permit Is for one hundred dollars($100)or leas.) MAP BOOK.- PAGE [PARCEL
AIR HANDLING UNIT,CFM
i BY I certify that in,the performance of the work for.which DISTRICT NO PROCESSED this permit ,- • ' ;�
I is issued, I shall not employ any person in-any manner so as to BOILER,BTU ✓
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU lY
APPROVALS DATEINSPECTOR'S SIGNATURE '
Date Applicant VENTILATION.SYSTEM "r
,'NOTICE TO APPLICANT: If, after-making this Certificate of ROUGH
Exemption,:you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions'of+the Labor Code, you must forthwith comply with such ' ' • FINAL' , 9
provisions or'this permit shall be.deemed revoked. ' ] FURNACE FAU G I
LICENSED CONTRACTORS DECLARATION, - / FLOOR BTU t " ' 6 VALIDATION
I hereby.affirm,that I amn
'licensed under provisions of Chapter 9 SUSPENDED UNIT a3.>
(commencing with Section•7000)•of'Division 3'of•the Business and, HEATER
.WALL
Professions Code,•and^my"license is'in full force'and effect /' CES f)tiTz�TS•
License Number §1q94-q-
"q Llc.,Class ,
Contractor Dateo
❑ I am exempt under•Sec. Plan check fee ., U
B.&P,C.for this reason PEFWIT;ISSUING FEE$
7, .O- OO
Date TOTAL FEE` a. O LU
U
Signature, Ill
OWNER-BUIL•DER'DECLARATION PLAN CHECK APPLICANT
I hereby affirm.that I amlexempt from the Contractor's License Law NAME,- D L for the'following reason (Section,7031 5, Business and Professions
.- , ADDRESS s'7 _E, a '.
I, as owner'of the'property, or my employees with'wages
as their sole compensation, will do the.work and the CITY TEL NO _
structure is not intended or offered for sale (Section 7044, F t t
.TyE _
Business and Professions Code) '. OWNER i
❑ I, as owner.of the.property, am exclusively contracting - w v l I_I Ts-AL-, 'r .5 2 8b
MAIL ,
with licensed contractors to construct the project (Sec- ADDRESS 'rtalra`: e•`I�
hon 7044;'Business and Professions Code)
HECK -
CONSTRUCTION LENDING.AGENCY CITYr. TEL. CHANGE r N E
lihereby affirm that there is a construction lending agency,for COINTRACTO
the performance of the'work for'which this permit is Issued ;
(Sec.3097, Civ C):
ADDRESS;
Lender's Name I l7 l t
` r, I z
CITY. = TEL NO. _ LI;t �._ j{ "}.0
3_
Lender's,Ad&ess 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 relto building construction,and hereby authorize r ,
representatives thi County to enter upon the above-mentioned
property fo I pe purposes.: SEE REVERSE FOR EXPLANATORY LANGUAGE -
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SIGNATURE OF APPLICANT OR AGENT 9 JDAT -