HomeMy Public PortalAbout10153 LA ROSA DR_Mechanical__ PW9/89
., WORKER'S COMPENSATION DECLARATION 20-0046'D ' 'APPLICATION FOR PERMIT
�76A364C - LIE':. GREEN
hereby.atfum that ['have a'certificate of consent to self;insure
or a cerSihcate"of workers CompensaLon Insurance or a certified ' 'HEATING.-VENTILATING -AIR CONDITIONING '
copy 1hEreyf(Sea'3800 Lab C.j,. - -
r l 7
Polley No.'r • ' Company - COUNTY OF LOS AN DEPT OF PUBLIC WORKS - 'BUILDING AND SAFETY.DIV. LLII
F-1 .Certdled copy is hereby furnished..
❑ .. Certified copylis filed with the county budding inspection+. .FOR APPLICANTTOFILL IN ODA ss
:0.department V 1 '
(PRINT, R TYPE L )
e dA .• ,.. .. '"
Data - AppllcanP-r - - : r LOCALI V
TYPE OF OR EOUIPMENTt FEE
CERTIFICATE,OF EXEMPTION FROM WORKERS • - - NEAREST
.. 4 .
•COMPENSATION INSURANCE "- ` ..•-- CROSS _
.' � '' j" ABSORPTION'UNIT,.BTU ASSESSOR
"
This,sectlon needfnot'be com leted if the work.involved b tha ; '
( ,. _ P ,- ,. Yr C. - '•• - MAPBOOK � PAGE '� PARCEL
ermit•is4or.one hundred•dollars $100 or less. I
P ,.i ( ) ) '' .,, :'AIR HANDLINGUNIT,CFM _ MTalrT no' PROCESSED BY
I cart,i that hhthe performance,of the work,for'whlch this,permit
Is Issued Ishall not.employ any peersonjo,any manner so-as to BOILER,.BTU
become subject to the Workers Compensation Laws j GGG L//L -
` COMPRESSOR BTU a0fl DtJ '
•' ' , ` - - APPflOVALS DATE 'INSPECTOR'S eIGNATORE
Date Applicant, y1ff6T94 VENTILATION SYSTEM •' ,, '
NOTICE TO APPLICANT If,'after,making this Certificate of ROUGH' -g
p y u1G become subject to the Workers' Compensation EVAPORATIVE COOLER ! m. -
7 pabor Code,'you.must forthwith comply with such - -' °
el
FINAL
Exemption,
a scans oroth shoermit shall be deemed revoked. K. FURNACE:' S FAU d GRAVITY q "' - -
rovls�ons of the•L 1l
LICENSED CONTRACTORS DECLARATION, / .FLOOR -'BTU �'� !� t '" VALIDATION .•} . -
I hereby.affirm that-I am licensed under provisions.Gf,Chapter.9 SUSPENDED "`UNIT- - -
,(com mencing with:Section 7000)•of•-0ivision 3 ofHEATER:fhe Business and WALL � - _ • :T��:� PY• ,
Professions Code antl"my Imerise is in full force and`effect. - r
License Nu m bar � Lic:Class SC�l • -
Contractor Ytbf,
,❑ " - L Plan check fee . .e O.
I.,am exempuander Sec.
I e&P C for this reason "`' - PERMIT ISSUING FEE $ / - 'O - - - 0
ate: TOTAL FEE ' (r
'
'Signature - d
_ OWNFR.6UILDER DECLARATION^ ` PLAN CHECK APPLICANT - ` CO
hereby affirm that am exempt,from the Contractor's License Law NAME -- , Z.
for fhe'IlolloMng reason (Section 7031.5, Business antl=Professions
Cotle).i'': ADDRESS - - - rA
❑ r
1, as owneof-the property, or my employeesr with wages I' I'
e .,.as their solea compensation will do.the-work and the CITU TEL:NO.
structure;is'not intenceo or.offered for.sale (Section 7044 '" - N
-.t BumneBa and,Pr`ofessicns Code) OWNER - ..TL!11]
❑ 1, as owner of the,property am ezclusi4ely contracting - TOTAL
'c {{--�� 9('
MAIL••. /L )IAL _ ._F' Y�0"
,.with licensed;contractors•t6 construct the prolect(Sec ADDRESS ,o' A V
`!tion 7044 Business Arid Professions Cade): '.'y d_
+e .• CITY 'TEL.NO:
" CONSTRUCTION LENDING AGENCY Lam• - " tI,A:16E
hereby affum ttia{;there Is a,construition'lendmg a9en cy+f or CONTRACTOR.
the performance'oi the'work�for which this permit Is esuetl G '► r =y s''X 1 r
(Sec. 3097 Civ. C)., . .. ,+' --ff - � / t r a •� { ,L,
c
ADDRESS. L� '/iw• .. Lif�I:ID I�IJ�%1 2l.-_. 1
Lender's Name .. - _ - �� ,>.n -. �['��(+� .,. )� T -
`: CITU ��, �. EL.NOQ/dam LVV c,�YY
..:Lender's Address - $TATE'6 UC. -
`.I certify that I'have read this application and state that the above uCENSE NO. � Z CLASS
"information is correct, I agree to comply With all County ordinances
and State laws ielating to building construction,ami hereby;authorize
representatives of;thism
,County to enter,upon the above- entioned
property for Inspection urposes._ SEE REVERSE FOR EXPLANATORY LANGUAGE
,SIGN. E _ C - DATE