HomeMy Public PortalAbout10135 LA ROSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I Gave a certificate of consent to self
insure, ora certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
O�o p�rfind copy thereof (Sec. 3800`, Lab. C.)
N /!.U/ IV .)4(per[(U f2 CE-818(REV. 10/81)
Pol i< o. Company_
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 / /3-t t' n department. ADDRESS U &S4
4
(PRINT OR TYPE ONLY)
Date / —� Applicant 1,q A&swva_ LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST -
COMPENSATION INSURANCE CROSS ST.
BTU
(This section need not be completed If the work involved by ABSORPTION UNIT, DISTRICT NO. PRO Eo eY
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_ / i .
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. / BOILER, BTU AP R-"I DALE INSP R'S SIGNATURE
Date Applicant / COMPRESSOR, BTU 3 Q 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 A
With comply with such ,provisions or this permit shall be
deemed revoked. FURNACE: FAU_ pvlT
LICENSED CONTRACTORS DECLARATION FLOOR BTUS V
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
'(commencing
USPENDED UNIT_'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full'fo/rce and effect. 2 � � d
N (fy37sfCLi .ESC10r76 O
License
umber S
2.
Contractor�"�/�F � Dole— O
❑ I am exempt under Sec. V '
- yr
d
B.BP.C. for this reasonPlan check fee N
Date: PERMIT ISSUING FEE $ /O Z
Signature TOTAL FEE S7d
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): +s
❑ I, as owner of the property, or my employees with ADDRESS y
wages as their sale compensation,will do the work and - ACCT.r
the structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). / /./n IM7 ITEMS 44.513
OWNER L " 1 I
El 1, as owner of the property, am exclusively contracting Ei 1.7
with licensed contractors to construct the project (Sec- MAIL 9 ` 1.4
C� nO Sf i l�(�L - t �
tion 7044, Business and Professions Code). ADDRESS JJ ,C
CONSTRUCTION LENDING AGENCY CITY , TEL. No. '/7 ( CHECK: 44.5C,
1 hereby affirm that there is o construction lending agency for & • 7 J'—J�/0
the performance of the work for which this permit is issued CONTRACTOR An , CHAHI,E .LII]
(Sec. 3097, Civ. C.). & (V4,1 e ,✓C
Lender's Name ADDRESS 9 �dC,N It'/+
ary T le �!�/ TEL. NO.U` •S - ovlad-ilUU1 A/1�1YCI
Lender's Address ' STATEq a p wuJ j AN11�:�
I certify that I have read this application and state that the LICENSE NO, Op 7 V CLASS CzV e 30 - `
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
up the havementionroperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
rtA��/Z or AW'k �aN�ate