HomeMy Public PortalAbout5756 LOMA AVE_Mechanical__ �P"' o a 10N DECLARATION .76A364C
ILv�S CON, L'+S CE-818(2-80) 6=�If— 1� L�- C AT IO FOR (fes E If�S MT
t� n;.il f-J) a a' certificate of consent to self:t
insure, rtitfca a of Workers'Compensation Insurance,or Q4EATING_bENTILATING-Al R CONDITIONINGa certifieykthereof'(Sec.3800,Lab. C.)
Policy No.—rti furnished,-
Compan
Certified copy is hereby y COUNTY OF LOS ANGELES '-BUILDING-AND SAFETY
.
Certified copy is filed with the county building inspection BUILDING .-,
department. FOR APPLICANT-TO FILL INADDRESS ;5 /Y.Z_ '
Date - Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE .
COMPENSATION INSURANCE NEAREST
CROSS ST. d
(This section need not be completed if the work involved,. ABSORPTION UNIT, BTU p
by the permit is for one hundred dollars ($100) or•less.) DISTRICT NO. PROCESSED BY O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM j� cc
permit is issued, I shall not employ any person in any manner51
V 0
so -as to become subject to the Workers' Compensation Laws. BOILER, BTU
/ f�,'�} - ' APPROVALS DATE INSPECTOR'S SI N>TURE W
Date Applicant COMPRESSOR,BTU-bc0 � v
ROUGH i _ _ U)
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply. with such provisions or this. permit-shall be VALIDA ION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
t I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT. j]
��(,commencing with Section 7000) of Division 3 of the Busi- , WALL (f
ness and Professions Code, and,my license is in full force and
effect. •
License Number Lie.Class
Contractor Date
3 am exempt from the licensing requirements as I am a. :0.13 9.5 A
licensed architect or'a registered professional engineer Platt check fee 25%of above.
acting in my professional capacity (Section 705 1, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ # 0..!? 0 0,08
Lic.or Reg.No. Date TOTAL FEE 1" To o 3050
HOME OWNER-BUILDER DECLARATION -PLAN CHECK APPLICANT o 0 - 3Q50'
I hereby affirm that I am exempt from- the Contractor's .NAME Q �,2 3-•$5
License Law for the following reason (Section 7031.5, Busi-
y ness and Professions Code): ADDRESS 77 All 46 AN/A
I, as owner of:the property, will do the"work and the
structure is not intended or offered for sale (Section CITY TEL. NO.Z�I�_ '�
7044, Business and Professions Code).
OWNER .ad /
EX
L, as owner of the property, am exclusively contracting
with licensed contractors to construct•° the project MAIL'
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO,
I hereby affirm that there is a construction lending agency
for the performance of the work for whichthis permit is CONTRACTOR
_`issued(Sec. 3097,'Civ.C.).
Lender's Name 'AD'DRESS
Lender's AddressCITY TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and y authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to iter i�o the above-mentioned propefty for
�s ctio rposes
i�l/�j _ .3-
Signature of Peir-nYittee Date
1