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Home My Public Portal About10134 LA ROSA DR_Mechanical__ WORKER'Shave a certificate DECLARATION 2G-G04(i DPW 9,89 APPLICATION FOR PERMIT LINE GREEN. 0A00 4C I hero+iy affirm that I have a certificate of consent to self insure, or a'certificate oLWorker's Compensation Insurance, or a certified - HEATING-VENTILATING -AIR CONDITIONING copy thereof(Sec. 3800 Lab. C.) _ - Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. t}❑ Certified copy is hereby furnished. ' LI Certified co .Is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING department. y 9 p (PRINT OR TYPE ONLY) ADDRESS LOCALITY Date Applicant NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' - NEARESTT. - CROSS S COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR- permit is for one hundred dollars($100)or less.)- AIR HANDLING UNIT,CFM _J2992_ MAP BOOK PAGE PARCEL DISTRICT NO. PROCESSEOCV I certify that in the performance of the workfor which this permit - is issued, I shall not employ any person in'any manner so as to BOILER,BTU 'become subject to the Workers' Compensation Laws. 7 / COMPRESSOR,BTU boo Date D L Applicant / APPROVALS DATE INCPECTOR'C RIGNANRE pP VENTILATION SYSTEM NOTICE TO AP LICANT: If, atter making thisCertificateof .ROUGH_ �7 Exemption,you'should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply.with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FA U GRAVITY - y ATION LICENSED CONTRACTORS DECLARATION FLOOR B U 1 hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED—UNIT— (commencing SPENDEO UNIT_ OD (Commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Cade, and my license is in full force and effect. - License Number / 7qV 7 LIL.Class C C 9 Cdntracto Date / Z , 0 1 am exempt under Sec. Plan Ch@Ck,fee7 1- V Cc BSP.C.for this reason PERMIT ISSUING FEE $ - ;N F.� O 17 Date: Z TOTAL FEE / V Signature Z I^11" Q. OWN&I R DECLARATION PLAN CHECK APPLICANT ��I t,AL _ 0) Z I hereby affirm that I am exempt from the Contractor's License Law NAME "f`-1-11 for the following reason (Section 7031.5, Business and Professions " Code): ADDRESS CHANGE A.4 f ❑ I, 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, — Business and Professions Code). OWNER ❑ 1, as owner of the property, am exclusively contracting. 4/ �MAIL I - - L " -S. with licensed contractors t0 construct the protect (Sec- ADDRESS 0 ) rofessions Code). tion 7044,CONSTRUCTION PLENDING AGENCY CITY /'= TEL.NO. i hereby affirm that there is a construction lending agency for CONTRACTOR C/ - , the performance of the work for which this permit Is !as uad _ (Sec.3097, Civ.C.). - ADDRESS Lenders Name CITUnw7peE449lika. NO. \ - Lender's Address - - STATE LIC. I certify that I have read this application and state that cap above LICENSE NO. 7 / � CLASS p 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 ' XWMrrWORKERS'COMPENSATIONDEC LARATION LICA ION FOR PERMIT affirm.ihat I have a certificate of consent to self Insure4or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING ore certified copy thereof (Sec. 3800, Lob. C.) CE-818(REV. 10/81) Policy No. Company r Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Pol Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING //.�s li, tion department. (PRINT OR TYPE ONLY) ADDRESS ` ✓ S l lr Date Applicant LOCALITY 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.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM t permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE. INSPECTO SIGNArylltE �Q d� Date —Applicant L�^ COMPRESSOR, BTU ROUGH d -� NOTICE TO APPLICANT: If, offer making this Certificate of VENTILATION SYSTEM FINAL Q� 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. FLIRNACE FAU_G VITY gi LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 O d I hereby off irm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ '(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full farce and effect. d O License Number Lic. Class polo WO Contractor Date O 1:1 ;@'4 4,3 5* am exempt under Sec to Plan check feed B.BP.C. for this reason - # • • • • • 8 tin PERMIT ISSUING FEES 10S Dore: I • • 3 0 S 0 Signature TOTAL FEE Z> ,I5- • • • 3 0 5&& OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - I hereby affirm that I am exempt from the Contractor's License , 0 Q 1 A-8 b 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 the structure is not intended or offered for sole(Section CITY TEL. NO. 7044, Business and Professions Code). ❑ NIG I, as owner of the property, am exclusively contracting OWNER G with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS r� 7 r (,� OST CONSTRUCTION LENDING AGENCY CITY TEL. NO. �2 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 TEL. NO, Lender's Address STATE LIC. I certify that I have read this applicotion and state that the LICENSE NO. CLASS _ .. above information is correct. I agree to comply with oil County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter up the ove- r e tioned prty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE upthe Signature of Applicant or Agent Date