HomeMy Public PortalAbout10206 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION PENSATIONDECLARATION 76A3-004a6
DPW 9189 APPLICATION FOR PERMIT LIAAE GREEN
70
.I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance', or a certified - .- HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company - COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKSBUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑
'Carl copy is filed with the county building inspection - FOR APPLICANT TO FILL IN ADORERS
.. department. (PRINT OR TYPE ONLY)
Data Applicant LOCALITY
- - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION.INSURANCE LGA �4
ABSORPTION UNIT,BTU ASSESSORpermit
t section need net be completed 0 the lworkess.)
Involved by the MAP BOOK PAGE PARCEL
permit i that..one hundred dollars f the or less.) Q x � O
AIR HANDLING UNIT,CFM olsmlcT NO. PPocEsssG et
I certify that in the'perlormance of the work for which.this.permit
is issued, 1 shall not employ any person in any manner so as to BOILER,BTU n
become subject to the Workers'Compensation Laws. :�
COMPRESSOR,BTU -
_ APPROVALS GAiE INSPECTOP'e 51GNANPE
Date ' Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of _ ' ROUGH -
Exemption you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY - -
LICENSED CONTRACTORS DECLARATION' .FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section'7000) of Division 3 of the Business and -HEATER: WALL ,
Professions Code,and my license is in full force and effect. -
AlZ �ti LG s
License Number _ Lic.Class
O }
a.
::. a. . O
Contractor Date - hAta.T.x _
❑ 'i am exempt under Sec. Plan check feeA - r ,�..11�„T IU` LI V
cc
BSP.C.for this reason PERMIT ISSUING FEE$ ;2-130 1, ITENS O.
- Date:' TOTAL FEE - TOTAi_� � -105 -.70 W'
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - - CHECK l�•U• I� fn
CHANGE
of Z_
.J��
I'hereby affirm that I am exempt from the Contractor's License Lew NAME - try
for the following reason(Section 7031.5. Business and Professions
ADDRESS
1,
'' �•. .
I, as owner of the property, or my employees with wages _ n n7/117/95
TTT as their sole compensation, will do the work and•Ihe 'tI�UG—J)�OZ
p CITU TEL.NO.
_structure is not intendetl or offered for sale (Section 7044, PM'f FM [I'f
;
Business and Professions Code). OWNER /[may is6 ���./ _ r
1, as owner of the property, am exclusively cont ract in MAIL
with licensed contractors to construct theproject(Sec- ADDRESS -
tion 7044, Business and Professions Code). -
' CONSTRUCTION LENDING AGENCY CITY. _TEL.NO.
c
I hereby afti}m that there is a construction lending agency.for CONTRACTOR -
the performance of the work for which this permit Is issued
(Sec: 3097,Civ.-C.)..
ADDRESS -
Lender's Name
_ - CITY TELc NO.
Lender's Address STATE S - LIC. •v - -
J certify that I have read this application and state tm it the above .LICENSE NO. CLASS [•
;information is correct.. I agree to comply with all County Ordinances
antlbuild
State laws relating to ing construction,and hereby authorize
representatives this County to enter upon theabove-mentioned
grope, r Ins action purposes. SEE REVERSE FOR'EXPLANATORY LANGUAGE
�-LIG SSS
SIGNAT E AP UCANT On AGENT