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HomeMy Public PortalAbout6420 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 ��������p,®nn ®� �'���n�y� HME ����� - ? hereby affirm that I have a certificate of consent to self Insure, 76A364C ' �fl �utl or a certificate of Worker's Compensation Insurance; or a certified HEATING-VENTILATING'-AIR CONDITIONING copy thereof(Sec 3800 Lab'C O 3. Policy No��G C atty `ro A4 COUNTY OF LOS ANGELES_ DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified cozpy is'hereby furnished r • BUILDING ' Certified copy Is filed with'the county building inspection FOR APPLICANT TO FILL IN ADDRESS 6.e (PRINT OR TYPE ONLY) depa ment n M/7e Date Z `•' Applicant (i•4S�ISA^�TITh�� LOCALITY E NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST L m��r-17��✓ ` COMPENSATION.INSURANCE I- 'ABSORPTION UNIT,BTU This section need not be completed If the work involved ASSESSOR ( b P Y the MAP BOOK PAGE PARCEL permit'Is for one hundred dollars($100),or less.) ' AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BV I certify'tFiat'In the,petformance of the work for which this permit ` Is Issued, I.shall not em to an erson In an manner so as to P Y. Y P Y- 'BOILER,BTU ' become subject to"the Workers' Compensation Laws " COMPRESSOR,BTU :qA'•, �, APPROVALS DATE INSPEC 'SSIGNATURE Date " 'Applicant - VENTILATION SYSTEM 1 NOTICE•TO APPLICANTIf, after making this Certificate of ROUGH . Exemption,you should,become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL1144 r provisions-.or,this'permrt,shall be deemed revoked •",. I FURNACE FAU VI �0 VALIDATION r LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed undertprovisions of Chapter 9 HEATER SUSPENDED UNIT (commencing wrth'.Seciion 7000) of,Division 3 of the Business and WALL " Professions Code,and my license,ls in full force and effect O r-L F TS t ©.v TcETS a- ' -License Number Llc Class Contractor K O M E,CF4Datefo •�r ��oO ❑ Plan check fee �� a 4 I-am exempt,under Sac i B SO C for this reason PERMIT ISSUING FEE$ O - U Date TOTAL FEE J� 1 TT � W Giq Signature PLAN CHECK APPLICANT - Cn OWNER-BUILDER DECLARATION TnT1 72_50, Z I hereby affirm that I am exempt from the Contractors License Law NAME. �r D for the following reason (Section 7031'5 Business and Professions 177„50 Code) ADDRESS �2 rE sA,✓�� LL ,P_.a S7' �� ❑ I, as owner of the property, or my employees with wages as their sole'compensation, will do the work and the CITYA-9-C� TEL NO .15-7Ie�7,7 ■00 structure Is not Intended;or offered for sale (Section 7044, Business and Professions Code) OWNER 7H A^/ ' ❑ I, as owner of the property, am exclusively contracting rVMMAIL O a �7f1L4—n�i1t ; with licensed contractors to construct the project (Sec-' ADDRESS 2.O tion 7044„Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY T' aTEL NO I herpeby a ffirm that there Is a construction lending agency for CONTRACTOR the er mance of the work for which this permit Is Issued (Sec 3097,Civ C) _ Lender's Name ADDRESS �2 S eE� �A^/�� � G A 2A V CITY AAL� % I A TEL NO Lender's AddressSTATE O b I certify that I have read this application and state that the above LICENSE NO O CLASS infoFination is correct I agree to comply with all County ordinances Ae Isreating to budding construction,and hereby authorize v isofenter upon the above-mentioned r Inspe Ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ?12-'7ff S RE OF APPLICPNT OR AGENT ATE '