HomeMy Public PortalAbout6442 LOMA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364 DPW 9/89 Rt li�fbl���A�I�Ai ®� ������ UME
GREEN
76A364C PMT"P 9 9 �tl
I hereby affirm that I have a certificate,of consent to self Insure, � � "
ort, certificate of Worker's Compensation Insurance, ora certified HEATING-VENTILA�'i'�G'-AIR CONDITIONING ,
copy thereof(Sec 3800 Lab C)
Policy NopC944022 Company Republic Indemnity COUNTY OF LOS ANGELES r- , DEPT OF PUBLIC WORKS' BUILDING AND SAFETY DIV.
❑,' Certified•copy is hereby furnished
❑ Certified co is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING /
PY 9 r ADDRESS ' C� 0.
-• department (PRINT OR TYPE ONLY) - -
01-01-95 0'Kane I Sales,', Inc LooA�ITY,
Date ApplicantNO TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS'' NEAREST
COMPENSATION INSURANCE CROSS ST ��z.,/` S' •• •{ ;
ABSORPTION UNIT,BTU ASSESSOR
(This'section need not be Completed If the work involved by theMAP BOOK PAGE PARCEL
permit is•for one'hundred dollars($100)or less)',r, AIR HANDLING•UNIT,CFM '
I certify that in tfie performance'of the�worl for which this permit DISTRICT NO PROCESSED BY
is issued,! shall not employ any person in any manner so as to BOILER,BTU
become subject•to the Workers'Compensation Laws 0 '
COMPRESSOR,BTU
Date • Applicant 'I APPROVALS DATE INSPECTOR'S SIGNATURE
VENTILATION SYSTEM a
NOTICE TO APPLICANT If, after making this Certificate of 'ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you,must forthwith comply with such FINAL
proyisions or'this permit shall be deemed revoked ' FURNACE FAU G VI
''LICENSED CONTRACTORS DECLARATION' FLOOR' - BTU VALIDATION`
I hereby affifm that I•am licensed,under prcvisions'of Chapter 9 SUSPENDED' UNIT—
(commencing
NIT(commencing wrtHEATER,I
h'Section 7000) of Division 3 of the Business and ' -- WALL -
Professions Code;'and my license is in full force and effect
Pc�J '/4c t
License Number 157 Lic Ciass C-20 }
Contractor'O'Kam &Sales, Inc- Date 06-30-95 _ _ r a0
❑ U
I am exempt'under Sec Plan check fee
B&P C for this reason PERMIT ISSUING FEE'-$ Q __(_ n �� 0
Date
'- TOTAL FEE �, y - �i `I��I`j��• ,. d
Signature" -
PLAN CHECK APPLICANTT t �
OWNER-BUILDER DECLARATION' - 'i) `t!L m '—� Z
I hereby affirm that I am exempt from the Contractor's,License Law NAME Dt1 t;
for the following reason (Section 7031 5, Business and Professions K I-*_ �•tt�1�4+�1_ t'�10 r
Code) ADDRESS t' i.Rt
❑ 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,
Business and Professions Code) OWNER Tv ` ( ii L'
❑ I, as owner of the,property, am exclusively contracting MAIL / ;I 1, _ 2 All, '" 'L•
with licensed contractors to construct the project (Sec- ADDRESS b Z
tion 7044, Business and Professions Code) t
CONSTRUCTION LENDING AGENCY CITY TEL NO
"hereby affirm that there is a construction-lending agency for ,+"-
Ihe performance of the work for which this permit is issued CONTRACTOR
(Sec 3097,Civ 'C)
ADDRESS' D r,4 �- - t•^ • -, - -
Lender's Name
CITY.
Lender's Address STATE // LIC t
I certify that I have read'this application and state that the above LICENSE No ' f b CLASS�� Z ro
Information is correct I agree to comply with all County ordinances ;
and State laws relating to budding construction,and hereby authorize
representatives of this"County to enter upon the above-mentioned
property for inioi purposes SEE REVERSE FOR EXPLANATORY,L'ANGUAGE
ATURE OF APPLICANT OR AGENT DATE '