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HomeMy Public PortalAbout6267 LOMA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION �F P H CAT.B O N FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers Compensation Insurance, IDEATING . VENTILATING - AIR CONDITIONING or a certified.{opy thereof (Sec. 3800, Lab. C ) 76A364C c 20-0046 DPW 9/88 Policy No. Company F-1. Certified copy is hereby furnished.• COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the courity by inspec- FOR APPLICANT-TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE'ONLY) Date Applicant LOCALITY—727m d04-c5 C Cel NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION'FROM'WORKERS" r NEAREST COMPENSATION'INSURANCE - I CROSS'ST •`(This section need not be completed if th@'work involved by VillABSORPTION UNIT, BTU - DISTRICT N PR ES D BY - the-permit is for orie•hundred dollars-($100) or less.) I certify that in the performance'of the work for which this AIR HANDLING UNIT,'CFM ��Q permit is issued,'I shall not employ a rson in any manner so•as to become sgQu/�b�.ject to the Work rs O pensa IOn Laws. / BOILER, BTU APPROVALS DATE. INSPE R'S SIGNATURE Date Applicant C ! COMPRESSOR, BTU �O ROUGH NOTICE TO APPLICANT. If, after making this Certif' to of VENTILATION SYSTEM FINAL Exemption,. you should become-subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER A #TI with comply with such provisions or this permit shall be deem= ' ed revoked. FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION' FLOOR BTU v 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' WALL- and Professions Code,;and my,license is"in fU`II force and effect.' CL -r- e. ,. .License Number Lic. Class. 0 D O Contractors O![/Q/P� ���ate I"'6'exempt under Sec.- R O Plan check fee W B.BP.C. for this reason N Date:' PERMIT ISSUING FEE $ Z TOTAL FEE' Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 I hereby affirm that I am exempt from the Contractor's License Law for the,following reason (Section 7031'.5, Business and, NAME• G Q �� D Professions Code): ' I, as owner of the property, or my employees with ADDRESS 1- v wages as their sole compensation,wIIl.do the work and CITY TEL 7& ACCUO e the structure is not intended or offered for sale(Section — 7044, Business OWNER'and Professions Code) � 3,9017 5i.l_II} ❑ dZa I, as owner of the property, am exclusively contracting LIJ ' le- with licensed contractors construct the project (Sec- MAILi TEMS tion 7044, Business and Professions Code). ADDRESS / /(J L TOTAL ® �� CONSTRUCTION LENDING AGENCY CITY TEL NO A I hereby affirm that there is a construction lending agency for G O (-HECK _3.(}I I the performance of the work for which this permit is issued CONTRACTOR, (Sec.'3097, Civ. C.). O CHANGE .Illi ADDRESS 'Lender's Name �Q CITY LL TEL NO. _ O.� 010001-000 1 8/17/90 9LI Lender's Address I cern that I have read this a Iicatlon and state that the STATE'. ` LIC. f f — i �,; certify pP LICENSE NO �g(? 2 CLASS — O i t�r7 t ' V L�ti • above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and/"by by authorize presentatives of this County to enter up th abo - n one property for inspection purposes '.SEE REVERSE FOR EXPLANATORY LANGUAGE SSignature of•Applicant or Agent' •Date / O ' '- •• - - _ _ • ©5