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HomeMy Public PortalAbout10150 LA ROSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION COp, PERMIT AI hereby affirm that I have a certificate of consent to self, A r f R PERM ' insure, ore certificate of Workers' Compensa io41n arance,' -76A364C _ HEATING - VENTILATING - AIR CONDITIONING , ansa e, o a cercopy thereof (Sec. s' 'p.DDgb DPW 9/88 - - 17 1 f" Policy ©`17 O_ pony COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is.hereby furnished.' - Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ^� tion'department. - ADDRESS " o (PRINT'OR TYPE ONLY) Dat Appic LOCALITY . . NO. TYPE OF APPLIANCE OR EQUIPMENT-- FEE CERTIFICATE.OF EXEMPTION FRO ORKERS' NEAREST . ' COMPENSATION INSURA CE _ - _ CROSS ST. -(This section need not be completed if the work Involved by ABSORPTION UNIi,'BTU DISTRICT NO - PROCESSED BY the.permit is for-one hundred dollars ($100) or less.) i I certify that in the performance ofthe work for which this AIR HANDLING UNIT, CFM- d6 D permit is issued, I shall not employ any person in any manner _ so as to become subject to the Workers: Compensation•Laws. BOILER, BTU APPROVALS DATEq INSPECTOR'S SIGNATURE ` Date I Applicant COMPRESSOR, BTU 'ROUGH �l7/U �(//`••(p •. r ' NOTICE'TO APPLICANT. If,:after making this Certificate o4 .. VENTILATION SYSTEM _ , - FINAL - 3O•%( 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 deem- - 1, ed revoked. I FURNACE: FAU R VIN - LICENSED CONTRACTORS DECLARATION FLOOR r• ' BTU '1 hereby affirm that I am licensed under provisions of Chapter 9 ..HEATER: SUSD UNIT - (commencing kith Section 7000)of Division 3 of the Business - WALLPEN ' and Professions Code,and my license is in full force and effggct. ` License N mber /`S.S Lic. Class ,, - d O ' r D - -9� U Confr a 0 - ' ,❑ 1 1 arr exempt' dei'Sec. •• ^�_ O Plan check,fee ' _ _ w 'B.&P.C. for this reason - w Date: PERMIT ISSUING FEE $ — Z Signature - TOTAL FEE ' OWNER-BUILDER DECLARATION - PLAN CHEK APPLICANT - I hereby affirm that I am exempt from the Contractor's License pop. - Law for the following reason (Section 7031.5, Business and- NAME - Professions Code): - ❑ Ias•owDer 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- --• - - TEL. NO. ACCT. ❑ F 7044, Business and Professions Code). OWNER ' I, as owner of the property, am exclusively contracting "3307 37.00 with licensed contractors to construct the project (Sec- MAIL 1.'ITEMS t�� tion,7044, Business and Professions Code).' ADDRESS ' CONSTRUCTION LENDING.AGENCY CITY • TEL. N }I_ITAL 37 . 00 I hereby affirm that there is a'construction lending agency for "- - ' the performance 6f the work'for which this permit is.issuedCONTRACTOR , 1:HE::Y 3'.1111 (Sec. 3097, Civ. C.). , y . - - LAADDRMS 3/ - . T CHANGI Lenders Name-, Y - TEL. N Lender's Address ' V f n TE ! uc. _ - 11100.0001. . 10/ 7x/•70 certify that 1 have read this application and state that the ENS NO. /J s� •CV+55 above information-is correct. l agree to comply with all County _ •. . . ,a 10` .1, - AMD3:713 ordinances and State laws relating to,building construction, , and here authorize representatives of this County,to,enter - - up v -m nti d perry for nspection pure0000sssseeees. - 0'- - /D�3' O SEE REVERSE FOR EXPLANATORY LANGUAGE - SignaNr of Ap nt or Agent. 'Date WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I herob�' affirm that I have a certificate of consent to self . _ 'n;uro, oro certf cote of W4Fkers Compensation Insurance, 75A364C - HEATING - VENTILATING - AIR CONDITIONING s` 6Icegifigd copy thereof (Sec 3800,Lab. C.) _„ q• '•��•••• + X20-0046 DPW 9/88 :+ r .icyl Company �, Certified copy is hereby furnished. - !) COUNTY OF LOS ANGELES ''BUILDING AND SAFETY. f _ .• FI, Certified copy is filed.with the county building inspec- FOR APPLICANT TO FILL IN - BUILDING tion department. - - - - (PRINT.OR TYPE ONLY) ADDRESS p��1191,5 .Date Applicant i- LOCALITY' - - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE- / G r. 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 s permit is Issued, I shall not employ any.person.ln any manner BOILER, BTU - ' ' So as to become subject f0 the Workers Compensation'Laws., /' / APPROVALS t DATE wSPECTOR'S SIGNATURE' t" r COMPRESSOR, BTU(,LCTj 'W� /-�► ROUGH /)7��( oL Pj �i.••rp. - t'Date App icant t NOTICE.TO APPLICANT:'If, after making this Certificate of _ VENTILATION SYSTEM - .. FINAL - ; Exemption, you•should become subject To the Workers '- I Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION . ' with comply with such provisions or this permit shall be deem- ed'ievokedr' `' • ' FURNACE,,, . FAV_G ITV 1 'LICEN . SED CONTRACTORS DECLARATION - FLOOR �BTU /--- I hereby affirm 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 force and effect. Licee Number Lic. Class T— g d ns - rD. .SuP , � ContractorDate - �; I am exempt under Sec. .,. Q Plan check fee w B.BP.C. for his reason. / a ,. e. PERMIT ISSUING FEE S — Z' _ Signature TOTAL FEE -9,! R- ILDER'DEC RATION PLAN CHECK APPLICANT .hereby m th t am exempt from the Contractor's license - - Low for the following reason (Section 7031.5, Business and' NAME . Professions Code): /Q - - ADDRESS - - - •' .try •I, as owner of the property, -or my employees with / wages as theirsolecompensation, will do the work and the structure is not intended or offered for sale(Section - TEL. NO. 7044, Business and Professions Code). -+-� - „- •I; as owner of the property, amiexclusively contracting OWNER yD3�fy a.� bJUi i tx-tE j.l,l.!I 1 (Sec- MAIL 1 1)Ltl�• wIle ith licensed'contractors to construct the project ' tion 7044, Business and Professions Code). r ADDRESS CONSTRUCTION LENDING AGENCY CITY, •. - O. ', TOTAL 65 . 00 I.hereby affirm that there is a construction lending agency for - , i SHE :!, 6-.00 the performance of the work for which this permit is issued CONTRACTOR � - (Sec. 3097, Civ..C.).• - - - - CHANGE ADDRESS - xa''rr��]E ,flil Lender's Name Lender's Address - CITY TEC NO. - - III QQ- Illi' I certifythat I hove read this application and state thot the STATE CLALIC-SS -' '" 7 i ,1 . .ifyU Pe LICENSE NO. CLASS -'L 1L above information is correct l agree to comply.with all County_ lU�t:{ ordinances and State lows relating to building construction;and hereby authorize representatives of this County to enter ' uponthe bov - entioned p ope fection purposes: - (,/[` SEE REVERSE FOR EXPLANATORY LANGUAGE' I t _ /a S' rel5licaril or Agent Date (vbs