HomeMy Public PortalAbout10136 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 7SA364C APPLICATION
p1� p4 p� C PERMIT y
I hereby affirm that I have a certificate of consent to self CE -818(2.80) A Ir Ir L IC/moi 1 I O 1 tl f 0 R Ir G R IVY IY
insure.or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES �i BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspectiondepartment. BUILDING
FOR APPLICANT TO FILL IN (] n•
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY `T�p Mrd A Qr/lx
CERTIFICATE OI'EXEMPTION PROM WORKERS' NO. . TYPE OF APPLIANCE OR EQUIPMENT FEE I'�/�tI VP
COMPENSATION INSURANCE NEAREST y
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(This section need not be completed if the work involved ABSORPTION UNIT, BTU C ROSS ST � ��� O
by the permit is for one hundred dollars ($100) or less.) OISTRICT NO. PROCESSED By U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cc
permit is issued, 1 shall not employ any person in any manner _ _ 0
so 0e -6—Z as to become subject to the Workers' Compensation Laws. BOILER, BTU
nn APPROVAIS DATE NSPECTOR'S SIGNATURE U
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.stelApplicant�_L,.QL64_4 COMPRESSOR,BTU ROUGHCL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become Subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO
with comply with such provisions or this permit shall be
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deemed revoked. / FURNACE: FAU_ RAVITY_
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license Is in full force and
effect.
License Number Lie.Class
Contractor Date
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25% of above.
acting in my professional capacity (Section 7051, Bus- '
iness and Professions Code). PERMIT ISSUING FEE $ SU
Lie.or Reg.No- Date TOTAL FEE 5_0 :2t6 6 3 4 A
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAME O\ � ��
License Law for the following reason (Section 7031.5, Busi- 2 r° - 2350
ness and Professions Coda): ADDRESS `O`4i6 fit, -Q.- _Q-2,
❑ I, as owner of the property, will do the work and the p L C ✓, 2 n ;o o • 2 3 5 0 H
structure is not intended or offered for sale (Section CITY TpAr,• It1 Dp &rL TEL. NO. il Ly L
7044. Business and Professions Code). 1x`11'1 11' "5 —_—J / lb 0 4'—8 2
❑ 1. as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project 'MAIL !
(Section 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 CONTRACTOR
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO.
1 certify that I have read this application and state that the STATE LIC.
above information is correct. 1 agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspe on purposes.
(P, b �I 82
Signature of Permittee Date