HomeMy Public PortalAbout10139 LA ROSA DR_Mechanical__ I/ - — I
TION
affirm that
t I have
a certificate
of corse APPLICATION FOR PERMIT
I herr affirm that I have a certificate of consent to self '
x✓ yl ar a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or certified copy thereof (Sec. 3800, Lob. C.)
CE-818(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 inspec FOR APPLICANT TO FILL IN BUBOwG
tion department. (PRINT OR TYPE ONLY) ADDRESS
Dote 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 ($1100)or less.) �, // 7( r
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM ,mss/ U
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Work s'Compensation Laws, APPROVALS DATE SPB oR's SIGNAWRE
COMPRESSOR, BTU ROUGH
Date�p If, ant Q
NOTICE n, APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL _te _
Exemption, you should become subject to the Workers" r
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VITV
LICENSED CONTRACTORS DECLARATION FLOOR BTU l (/
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPE DED UNIT_
'(commencing with Section 7000)of Division 3 of the Business
and Professions Code,and my license is in full force and effect. d
a.z O
License Number Lic. Class - , U
Oc
Contractor Date O
U
❑ I am exempt under Sec. �b 8 5 b A W
Plan check fee
B.BP.C. for this reason' #1e e e e e 8 W
' PERMIT ISSUING FEE $ :207—
Date: ( -'- 3275
Signature TOTAL FEE2
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT e e e 3 2 7 5 5
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and NAME 1.4 , '0 0 5 t 8 7
Professions Code):
❑ 1, 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 sale(Section CITY / TE N
7044, Business and Professions Code).
Ow1E'R
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). AD E55 r
CONSTRUCTION LENDING AGENCY CI TEL Ni
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACT R
(Sec. 3097, Civ. C.).
ADDRESS -
Lender's Nome
CITY TEL, NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
an her uth n re esentatives of this County to enter
u n f( Dive m noon roper for spectian purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Ap im or gent Date