HomeMy Public PortalAbout5925 LOMA AVE_Mechanical__ ION
DECLARATI
V1IbRKER'SCOMPENSATate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm„that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec. Lab.C.) �^
Policy No. 1 /q1aO_ &mpany / r� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
L_) Certified copy is filed with the cou building inspection FOR APPLICANT TO FILL IN BUILDING
g ADDRESS 9, � L
department. _,rW r (PRINT OR TYPE ONLY)
Date ? Applicant `��t? NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY T' �C` 7 y
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTCROSSU ASSESSOR
(This 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 L
is issued, I shall not employ any person in any manner so as to BOILER,BTU v
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU ��� J� G
- 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 VO
_2
provisions or this permit shall be deemed revoked. FURNACE: , FAU GRAVITY �{
LICENSED CONTRACTORS DECLARATION FLOOR BTU aDO ✓ VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED 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.
_7_A.'< rTs OCo-TLG%� It7
License Number 5—,�'o$12 Lic.Class
CL
Contractor Oi?10.11�41'”/1 A Date 7_31-23 , - O
ElI am exempt under Sec. Plan Check fee -
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V
ne _
B.&P.C.for this reason PERMIT ISSUING FEE$ Kc, '` =y= 0
Date: TOTAL'FEE _ -1011=' W
Signature tY'+ '�4 �,=:' G-
PLAN CHECK APPLICANT �f-i i-tf _ CD
OWNER-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law NAME , f^'i`'"'
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
El 1, 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, ; ,"I°�7=
Business and Professions Code). OWNER O 7-- _ � -
❑ ^l1f '
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS G L O/¢
tion 7044, Business and Professions Code). CITY TEL.NO. �rJK r
CONSTRUCTION LENDING AGENCY /�rrrPCC /7 7 -/14-cS
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS Q
1 2 S C, 0
Lender's Name
CITY ZLc /1 �J� TEL.NO. C7� 0 9
Lender's Address STATE // �7 LIC.
I certify that I have read this application and state that the above LICENSE NO. [o O 9 CLASS ( �t J
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
repre tatives of this County to enter upon the above-mentioned
pro ert for' spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT UK F&ENT DATE