HomeMy Public PortalAbout4970 LOMA AVE_Mechanical__ ION
WORKER'S have
a certificate
of consent to 200046 DPW 9/89 p(��II �IY�/�1 1T�®II CI ®� PERMIT MME
� FF
�`?\ 76A3saC lr L� CL/6'il A
I hereby,'��rm the I have a certificate of consent to self Insure,
of a certlNc3le of Worker s Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING'
copy•thereof(Sec;3800 Lab_C) J I I.
Policy No Company - COUNTY OF•LOS ANGELES DEPT OF PUBLIC-WORKS BUILDING AND SAFETY DIV. LLll11
❑• Certified copy Is hereby furnished ;
DCertified co Is filed with the coup buildin Ins ection FOR APPLICANT TO FILL IN BUILDING /
departmentpy 9 p (PRINT OR TYPE ONLY) ADDRESS Q
Date ~Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY e g r
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE O h
ABSORPTION UNIT,BTU ASSESSOR -
IT section need not,be completed if the work involved by the MAP BOOK PAGE PARCEL
.permit is,for.one,hundred dollars($100)or less.) - AIR HANDLING UNIT,CFM '
DISTRICT NO PROCESSED BY'
I certify.that'In the performance of the work for which this permit _
is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws
COMPRESSOR,BTU (O
APPROVALS' DATE INSPECTOR S SIGNATURE"
Date Applicant VENTILATION SYSTEM '
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the=Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL '1
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O VA ID TI N
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section,7000) of Division 3 of the Business and HEATER WALL
Professions Code,and my license'is In full force and effect
' •� yam, — .. ..
License Number Lic Class o
Contractor Date JL
❑ - ACCT.
lam exempt under Sec Plan Check fee " ' V
B&P C for this reason PERMIT ISSUING FEE$ 3303 118.Wil]"Q
1• ITEMS
Date TOTAL FEE U
- TOTAL 118 -50 w
Signature m d
OWNER,BUILDER DECLARATION PLAN CHECK APPLICANT IIu{�E^^rC'Y� 118.,:,y Z
I hereby-affirm that I am exempt from the Contractor's.License Law. NAME and Professions r . r:S Q /\ D Cnf7�4E e0U
for the'following reason (Section 7031 5, Business
Code) ' . ADDRESS
❑ I, as owner,of the property, or,my employees with wages �� VC �ynitn art t
70
as their sole compensation, will do the work and the CITY�'� TEL NO �3•- s VLIVV-VtJ�1 �� 0���
structure Is not intended or offered for sale (Section 7044, f O
Business and'Professions Code) OWNER Sa m } 6775 t AM 9:34
d I, as owner-of the property, am eicclusively contracting
MAIL
with licensed,contractors to construct the project (Sec- ADDRESS sd NZ e r
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Is a construction lending agency for CONTRACTOR
D .a
the.performance of the work for which this permit Is Issued
(Sec 3097,Civ C) c-vc
ADDRESS
Lender's Name
CITY TEL NO-
Lender's Address STATE LIC . 1 --
I certify that I have read this application and state that the above LICENSE NO CLASS
Information Is correct' I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
re entatives of this County to enter upon'the above-mentioned
r p ty for ns a ion,purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLJCA T OR A DATE '