HomeMy Public PortalAbout10129 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 76aoaC 9169 APPLICATION FOR PERMIT LANE GREEN
6A384C
hereby affirm tf:at have a certificate n consent to self insure,
or a certificate c Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
,C'o'py ih of(Sea 3800 Lab.C.)
�P611 No/ Company (�£`�a/ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ - Certified copy is hereby furnished.
Certified copy is filed with the coy t building inspection FOR APPLICANT TO FILL IN BUILDING
Y 9 P ADDRESS
d partmenL n (PRINT OR TYPE ONLY) ��yy
Date/77ZA__Applicant /L LOCALITY NO.
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NO. TYPE OF APPLIANCE OR EQUIPMENT FEE v
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed(S1 if the work involved by the MAP BOOK PAGE PARCEL
permit is for one huntlred dollarss(5100),or less.) AIR HANDLING UNIT,CFM
OISTFlILT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner s0 as to BOILER,BTU D
become subject to the Workers' Compensation Laws. %S p
L COMPRESSOR,BTU
APPROVALSDATE INSPECTOR 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 t /
provisions of the Labor Code, you must forthwith comply with such - FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 7 5 LIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT—
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full tome and effect. ,
License Number�Lic.Class
a
ContractoygqA�� / e V
❑ I am exempt under Sac. Plan Check fee Q
SAP.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE d
Signature U)
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Cade):.
❑ hvL•
1, as owner of the property; or my employees with wages ADDRESS 1 r T
—
as their Sole compensation,.will do the work and the CITY TEL.NO. b i(i tit v$J
- structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL TOT AL 3 7 - 00
with licensed contractors to construct the project (Sec- ADDRESS IJ _
27
tion 7044, Business and Professions Code). C �'Cl X I .t u
- CONSTRUCTION LENDING AGENCY CITU -e_ TEL.NO.if
hereby affirm that there is a construction lending agency for i , '=Ftn:i�� a•.I
the perio rmance of the work for which this permit Is issued CONTRACTOR
(Sec. 3097, Civ. C.). 61
Lender's Name '/ i +I i
ADDRESS / .x /� C.!01313-110101C.!01313-110101C.!01313-110101ifiisr.1
h
CITU TEL.NO.
Lender's Address STATE LIG A
I certify that I have read this application and state that the above LICENSE NO. P CLASS 02 Il
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
proper or' action purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
j ,10� _
el A F I NT OR AGENT OAT