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Home My Public Portal About6019 LOMA AVE_Mechanical__ i •WORKERS:COMPENSATION DECLARATION + e �p S 7 �I herebyaffirmothat I hove a_certiflcate of consent to self APPUCATM -FOR PERMIT �� insure, or a certificate of Workers' Compensation Insurance, 76A364C : . ' HEATING - VENT,ILATING•-' AIR CONDITIONING or a certified copy theieof (Sec. 3800, Lab. C.) CE-818,(REV.'10/81) Policy Na.' PC,93395 company Republic. Inde-mnity ❑ .61rtified copy is-hereby furnished. COUNTY OF-LOS ANGELES Templ-e City BUILDING AND SAFETY Certified copy is file h the nt g-ins FOR APPLICANT TO FILL IN- BUILDING Tion d part ent, ADDRESS 6019 'Loma St'. 7- ;Z-. -. (PRINT OR TYPE ONLY),,. Date Ap,licant LOCALITY -Temple' City / NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION ROM W RK S'. NEAREST COMPENSATION INSURANCE CROSS ST. ' ABSORPTION UNIT, BTU '(This section need not,be completed if the wort(in VolVed by• DISTRICT NO. ° PROCESSED BY the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT;CFM I certify that in the performance of th"e'work for which this, • permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECT 'S SIGNATURE Date Applicant / COMPRESSOR, BTU ROUGH1Z.1 AZIA NOTICE TO APPLICANT: If,•after making this'Certificate of VENTILATION SYSTEM FINAL Exemption, you 'should become subject .to the Workers' Compensation provisions*of the Labor Code, you,must forth EVAPORATIVE COOLER ALIDA with comply with such provisions or this permit shall be deemed revoked: 'FURNACE: EAU VITY f✓ LICENSED CONTRACTORS DECLARATION, FLOOR BTU I hereb irm that I am licensed under provisions of Chapter 9 SUSPENDED •UNIT ` (c m e ci with Section 7000) of Division 3 of the Business HEATER: WALL d r ions Code,and my license is,in full force and effect. / "" ' 9 3034.00 . C-20 �Q - 5 0 ns N m er LIc. Class - V on r or Aa, Date_� �3 - 0 ❑ I am exempt under Sec'. W Plan-check fee N B.&P.C. for this reason Date: 'PERMIT ISSUING FEE-$ ® — z Signature' TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the.Contractor's License Law for the following reason (Section 7031.5,. Business and NAME Professions Code): ❑ I, as own_er' of the property, or my'employees -with ADDRESS # z O 4 2,11L compensation, will'do the work and wages as their sole `o o.o t6,0 8 the structure is not intended or offered for sale(Section' CITY TEL. NO. 7044, Business and Professions Code). OWNER 4 9_75 ❑ I, as.owp ner of the.proerty, am exclusively contracting WOrrel & Fitzgerald with licensed contractors to construct the project (Sec- MAID' - c`o io 4 9,7 5 v tion 7044, Business and Profession'stCode). ADDRESS 306 Harvard Dr. CONSTRUCTION LENDING AGENCY CITY TEC NO. 213-447-9339 Arcadia 91006 I hereby affirm that there*is a construction lending agency for t '�8,,1 b`s 8 8 the performance of the work for which this permit is issued CONTRACTOR Gibson S 'Komfort Ai:r, JnC. (Sec. 3097,.Civ. C. ADDRESS Lender's Name 13240 Raymer St. - ... .,_ : Lender's Address CITY. ' Hollywood ' 91605L.,No. 982-661.0- . STATE ` LIC. C-20 I certify'that.I have.read this application and state that the LICENSE N303400 O. . CLASS, - _ above information is correct. I agree to comply with all County ordinances an State ,laws'relating to building construction, and er by u horiz epresentatives of this County to enter u n It e a o tioned property four)nspectiorl purposes, SEE'REVERSE FOR EXPLANATORY LANGUAGE • '?ignature p ant or Agent .Date • - - - _ ... . _ ;. _ M .id WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to srelf insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy No. +RL::: i.:-2 Company ^n��2 r1Y i;!! 17 { ir: Certified copy Is hereby furnished. COUNTY OF LOS ANGELES ',V."1',1*0 L j BUILDING AND SAFETY Certified copy is filed,;kith the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS ?�.IV cy?'.'�L er.'t'Ir. Date Applicant LOCALITY .o1 y City NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM 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 become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU - GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU ' I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business WALL a and Professions Code, and my license is in full force and effect. O License Number Lic. Class ► w U_ Contractor Date y ❑ 1 am exempt under Sec. Q Plan check fee B.BP.C. for this reason O PERMIT ISSUING FEE $ a Date: TOTAL FEE Lu Signature ?- OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS �+!`� wages as their sole compensation,will do the work and CITY TEL. NO • • * • • t the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER tzOL»n El �.....�.. ,. 'f I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL t.. •�+ -. e r w } tion 7044, Business and Professions Code). ADDRESS !! CONSTRUCTION LENDING AGENCY CITY "" " ' ''V TEL NO. I hereby affirm that there is a construction lending agency for * r c the performance of the work for which this permit is issued CONTRACTOR ► t (',: (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY ',^00 t;'n1....�" <f' 49 f .v.a=t<+.ISL NO. Lender's Address STATE t"?.,i '`tip.-' LIC. I certify that I have read this application and state that the LICENSE NO CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and.hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE `Signature of Applicant or Agent Date