HomeMy Public PortalAbout6228 LOMA AVE_Mechanical__ f L/ORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 �I�f�ll �/ia 6a 9P�®II�1 Ir®� ��If11�Htl��LJ. 76A364CPU'L� CL�'il IILl ME ,
that;l have a certrficate of consent to self Insure,• - eee 777 \���»JJJ[[C111ttH�� L�LLL��� 411f
' or a certificate of Workers Compensation Insurance, or a certified HEATING-VENTILATING� R`6ONDITIONING
copy thereof(Sec-380Q Lab C)
Policy Nd'—. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.'
❑ Certified copy is hereby furnished
0 ,Certified copy Is filed with the county budding inspection FOR APPLICANT TO FILL IN BUILDING
department , - (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
•. r NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
section neenot e completed if the work Involved b the ASSESSOR
( .This id b
p y 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 fo/whic h pe Itis issued, I shall not employ any person in ano to BOILER,BTUbecome subject to the Workers' Compensa idn La
' A COMPRESSOR,BTU
APPROVALS 'DATE INSPECTOR'S SIGNATURE
Date ,Applican ' VENTILATION SYSTEM '
NOTI TO PLICANT If, aft r 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 GRAVITY
LICENSED,CONTRACTORS "TORS DECLARATION FLOOR BTU to VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of'the Business and WALL
Professions Code,and my license Is in full force and effect,
• JG/� /JyI _
License Numbery w Llc Class• ✓26
Contractor"' �✓ Date" � _G'�i O
❑ a' U I am exempt under Sec �� / _ E
B&P C for this reason PERMIT ISSUING FEE
1L v
Date TOTAL FEE' 02 jTEJ W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT S F g � Z
I hereby affirm that I am exempt from the Contractor's License Law NAME D L 3 t Z
for the following reason (Section 7031 5, Business and Professions -'l7il�` 21 .°1Ct
Code) ADDRESS i_3TtTi"11,7E °oij-
1, 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, _r f,-,1
Business and Professions Code) OWNER ^�� its Ift's—_ j(� ii II�iX L 74
❑ I, as owner of the property, am exclusively contracting MAIL �� / i�k3 1 Am 10:=?
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code) �.p,^�
CONSTRUCTION LENDING AGENCY CITY 1 l /// �l TEL NOL
I hereby affirm that there Is a construction lending agency for CONTRACTOR r D
the performance of the work for which this permit is issued ,
(Sec 3097,Civ C) -
.i /�✓��1 ��
Lender's Name ADDRESS
CITY ,%w TEL NO
Lender's Address
STATE LIC
I certify that I have read this applicati and state that•the above LICENSE NO CLASS
information Is correct I ag co with all County ordinances
and State laws rating to ing o s ruction,and hereby authorize
representati hof this ty �� r upon the ab ve-menti Heil
property pecti rp SEE REVERSE FOR EXPLANATORY LANGUAGE
A E P OR DATE ,