HomeMy Public PortalAbout10043 LA ROSA DR_Mechanical__ WQRKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-BN?(REV. 10/81)
Policy No. - Company
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspeo FOR APPLICANT TO FILL IN BUILDING D
hon department.
(PRINT OR TYPE ONLY) ADDRESS
-
vqDate Applicant - LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS sr. -
(This section need-not'be completedifthe work involved by ABSORPTION UNIT, BTU mSTRlci rvo. PROCESSED.BY
the permitisfor one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, )shall not employ any person in any manner -
so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE If CTOR'S SIGNATURE
Date S-� /6/� My-�7FzdRAppli<ant COMPRESSOR, BTU ROUGH
U y-
NOTICE TO APPLICANT: If, after ma g this Certificate of 'VENTILATION SYSTEM FINAL
Exemption, you should become su ject 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 EAU 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 1610o
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class - ' V
d'
Contractor Date - O
H
❑ I am exempt under Sec. -9 9 6.1.0 A d
Plan check fee -
B.BP.C. for this reason' N
- PERMIT ISSUING FEE $ D •.D # - is -,e *.8 Z
Date:
Signature TOTAL FEE '1 • • 2 Q 5 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ✓ - - Is Is 2'Q 5 0.5
I hereby affirm that I am exempt from the Contractor's License -
Law for the following reason (Section 7031.5, Business and NAME , 0 5 1 b y 8 8
Pro ssions Code):
1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO,
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting _ r
with licensed contractors to construct the project (Sec- MAIL - -
tion 7044, Business and Professions Code). ADDRESS Lb .3 IZ4GS
CONSTRUCTION LENDING AGENCY CITY e� /P �/ •f TEG NOr��
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 .. [ NO. - -. -
Lender's Address
STATE /
I certify that I have read this application and state that rhe CL 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-rent a roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
' FT
Signa Nr f Applicant or Agent - Date