HomeMy Public PortalAbout10144 LA ROSA DR_Mechanical__ WORKERS,COMPENSATION DECLARATION
I hereby ntffrcrn that I have a certificate of consent to self,. - APPLICATION 'FOR PERMIT -
•insure, or a ceitificote�of Workers' Compensation Insurance, 76A364C ;;HEATING VENTILATING - AIR .CONDITIONING
ar a cerhfied'Eopy thereof'(Sec. 3800,.Lab. C.) __ ,•
'CE-818(REV. 10/81) _ - - ^• . 1'
Policy No. - Company - - - -CIO LOSANGELES'+ - _ r BUILDING.AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with'tfie county building in spec - FOR APPLICANT TO.FILL IN -• - BUILDING 1.444-
!inn
.-^
tion de artmew. 'ADDRESS d '-�^T
P , _. _ (PRINT OR TYPE ONLY) -
- LOCALITY f
• Date Applicant NO TYPE OF"APPLIANCE OR EQUIPMENT.' FEE'
' CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST'
-_- ..
'•' COMPENSATION INSURANCE CRO55 ST.
ABSORPTION UNIT;BTU' - oISTRIct No:' PROCESSEo
(Thizrsection need not be completed if the work'involved.by _ . (/ •
the permit is For one'hundrad dollars ($100)or less.)' . 6
r
I.certify that in the performance of the'work:for which thisAIR HANDLING UNIT 'CFM
, , _
'permit is,issued, I shall not employ any person in any manner `
so as to become subject to the'Workers'CompensationBOILER, BTU
Laws. APPROVALS - :D.ATE IN CTOR'S SIGNATURE
BTU((� , �Z8"D-U v ROUGH
Date//�T �t' � t Applicant COMPRESSOR,_ _ -
NOTICE TO, APPLICANT:'If, after making this Certificate:of VENTILATION SYSTEM FINAL '
Exemption, you should became subject to the Workeis' ` - _ - - ,
Compensation provisions of the Labor Code, you must forth`- EVAPORATIVE COOLER'.. - (VALIDAT N
with 'comply with such provisions,or this'permit shall be.
deemed revoked 'FURNACE:' .. FAU" 'GR VI Y `/l
- LICENSED CONTRACTORS DECLARATION FLOOR' BTU v
I hereby affirm thatPam licensed'under'provisions of Chapter 9 HEATER' SUSPENDED UNIT - - -
(commencing with Section 7000) of'Division 3 o.the Business WALL -
and Professions Code,Qand m�y'li`ctinse is in full force and effect. - d
License Number s ` 1 Lic,Class G—LO - - ' - - - - , U r
Contrador71:T� Date -
❑ .. _ - _ - U
I'am exempt under Sec. d
Plan check fee ''-� = ��
B.BP:C. for this reason - N
-- - PERMIT-ISSUING-FEE $' .'� - - 2
Date: -
Signature TOTAL FEE - ;29423A
OWNER-BUILDER DECLARATION - PLAN CHECK APPLICANT - .
Thereby affirm that I am exempt from the Contractor's License.- - - - # e • • '• '• '8'
Law for the'following reason(Section 7031.5, Business and NAME - _ ,I ,� 4 Q 5 Q
ls
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). - - - "' -7 ' '- '- - Q Q ,9`- $8
OWNER-
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- •t, MAIL -
44 cA
Non 7044, Business'and.Professions Code). ADDRESS L (� �.
CONSTRUCTION LENDING AGENCY" CITY TEL.NO. 4d;41tA"" -
Thereby affirm that there is a construction lending;agency-for - -
.the performance of the workfor.which this permit isrissued' CONTRACTOR ' - - - -
(Sec. 3097-Civ. C.). . -._T C
.. - .ADDRESS
Lender's Name ,.
r CITY �// n. -1 ..- TEL. NO. _ ,� -• _ - _
Lender's Address ��""ttt/// '
certifythat have read this a lication and state..that the _ STATE LIG n
PP LICENSE NO. CLASS 4}.0 -
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 - •" - ""
upon the obove-mentioned property for inspection.purposes. SEE REVERSE.FOR:EXPLANATORY LANGUAGE. - -
Signature of'Appliconi or Agent Ddte�