HomeMy Public PortalAbout6034 LOMA AVE_Mechanical__ fi that'
COMPENSATION DECLARATION APPLICATION FOR PERMIT'
lff�r� that I have a certificate of consent to self
r o,s�ssa ;ertiflcate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR 'CONDITIONING
• :=or a ter3ik*ed copy thereof (Sec. 3800, Lab:C.)
k, CE-818(REV. 10/81)
Paolicy No.��f.�f�-Company2QiY"�.o /
Certified copy is hereby furnished. COUNTY OF LOS ANGELES. - BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN. BUILDING D��
tion department. v ADDRESS
(PRINT OR TYPE ONLY)
Date -7—,�X Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
.CERTIFICATE OF EXEMPTIW 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 (000)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 IN C ORAS SIGPATURE
COMPRESSOR, BTU /�Q06,'d a Q Z) �d ROUGH I
Date Applicant
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:. FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm than am licensed under provisionsof'Chapter 9 HEATER: SUSPENDED - UNIT'(commencing with Section 7000) of Division 3 of The Business WAL �
and Professions Code,and my license is in full force and effec t. 2� /( 0
0 (Jr CL
License Number _ Lic. Class
C` V
09
Contractote 0
aU
I am exempt under Sec. LU
Plan check fee a.
B.BP.C. for this reason PERMIT ISSUING FEE $ ;9 9.3 1L2 A Z
Date:
TOTAL FEE "0,0:0,0!0 8
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT d -67 8.5 O
I hereby-affirm that I am exempt from the Contractor's License /�,�
Law for the following reason (Section 7031.5, Business and NAME' '/•� t' ®?s o % 8 5 0 x
Professions Code):. - �.
El. I, .as'owner of The property,' or my employees with =6 8 � � ;fcy-rev&j ,iC` Q 4,,0 71-.8 8
wages as their sole compensation,will do the work and /
the structure is not intended or offered for sale(Section CITY. 2' TE.L. NO.
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors*to construct the project'(Sec- MAIL
tion 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 which this permit is issued CONTRACTOR.
(Sec. 3097, Civ. C.).
ADDRESS + _
Lender's Name
CITY j-7 r TEL. NO. '
' Lender's Address / tc-1� q _
I certify that I have read this application and state that the STATELICENSE NO: P sr rfo od !: •- LI ASSD-
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 th above-mentioned pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,gnature of Applicant or Agent' :Date -' -
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