HomeMy Public PortalAbout6209 LOMA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION
;b he'r�y'dffitm that I have a certificate of consent to.self ,
.-APPLICATION FOR PERMIT
insure .ora certificate of Workers' Compp,nsation Insurance;. 76A364C- HEATING VENTILATING - AIR CONDITIONING
or a•certified copy thereof (SecJ3800-Lab. C ) `
T CE-818(REV: 10%81')'
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Policy No.t� Company�TY` �� _'
Certified-copy is-hereby furnished: COUNTY-OF LOS ANGELES BUILDING AND SAFETY
Certified copy is'filed with the county buildin ,inspec_ FOR'APPLICANf lO FILL IN• BUILDING ' y
/
hon department. ADDRESS �V �l l '
Date `r�a APPlicant
(PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE
LOCALITY
CERTIFICATE Or EXEMPTION FRO WORKERS' NEAREST
COMPENSATION INSURANCECRO SS ST.. .
(This section need not be completed if.The work invol'veil.by.. ABSORPTION UNIT„BTU olsrRicr No. PRo seo
the permit W.for one hundred dollars'($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
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permit is issued, l'shall not employ any person in.any manner _
so•as to become iubject to, BOILER, BTU'xhe Workers'Compensation Laws. aPPRovals Dare. iN ecroa•s sl aruRe
�
Dare Applicant - COMPRESSOR,BTU r
n ROUGH ( '
NOTICE .TO APPLICANT:'if,-after making this''Cerfificate of VENTILATION SYSTEM FINAL
Exemption, you should` become subject. oto the Wo"rkers'.
Compensation provisions-of-the Lobo'r Code; you must forth- EVAPORATIVE COOLER` VALIDAT
with,.comply with such,provisions, r this'permit shall be
deemed revoked.,
FURNACE: FAU QRAVITY
LICENSED CONTRACTORS.DECLARATION FLOOR BTU jG 42,
I hereby affirm tfiat.l pm licensed under provisions of Chapter 9 SUSPENDED UNIT
HEATER: WALL
*(commencing'with Section 7000) of Division 3 of the Business '
and Professions Code,'ond-mylicense is in'full force and effect.'
-2 C-Zd r --
License Number Lic, Class ® U
Contra_cTor Date, 0
❑ I am exempt under Sec U
'Plan check fee
.. H
B:&P 6. for this reason PERMIT ISSUING FEE $
` Date:" �
Signature
TOTAL,FEE (,
OWNER-BUILDER DECLARATION:-'_ PLAN,CHECK APPLICANT,
I hereby affirm that I am.exempt from the Contractor's License'
Law'for the'followmg reason (Section 7031.5, Business and' NAME '
,Professions Code):
0 ' I; cis owner,of the property, or my employees with. ADDRESS
wages as their sole compensation,'will do the work a-nd'
the structure is not intended or offered for sale(Section CITY TEL. NO. .
7044 Business and Professions Code). -"
OWNER,' t a
I, as owner.of the property,am exclusively contracting' _ <<' f �'
with licensed contractors to construct the project (Sec- MAIL
- tion 7044, Business and Professions Code).' ADDRESS 7 O;� w✓\f-\ /y �+4- ;258,21
j A '
CONSTRUCTION LENDING AGENCY"
CITY'.,'"Tt ,U C'� '."TEL NO.
t hereby affirm that there is a construction lending agencyfor l ° ° °'0;0 8
the performance of the work for which:this permit is issued CONTRACTOR' TG t E A�L.
(Sec. 3097;Liv. --
ADDRESS tJ~I: 1�1` I��� _
�v`- I ° ° 44.56
f �. ,.._ ° m 4`4-50 - ...
_ o ,
Lender's Name- 0.
CITY. T TEL...N , Z�
Lender's Address
N� ,t is Lc O
STATE LIC. f`
I certify that I have read this'a application Ono state-that the -
Y PP LICENSE;NO: Z' CLASS
above information1s correct..]agree to comply with all County x
ordinances and State laws relating to building construction; :-•
and hereby.authorize representatives of this County to enter
upon�vemed property for inspection purp ses. SEE REVERSE FOR EXPLANATORY,LANGUAGE.
.,._ _
..'i,- -e•of Applicant orA rit '; Date