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HomeMy Public PortalAbout10212 LA ROSA DR_Mechanical__ DEC WORKERS CI have COMPENSATION cafe ofA ON APPLICATION . FOR PERMIT j - I hereby affirm that I have a certificate of consent to self � J� insure,-or,a certificate of Workers'-Compensation Insurance,• oro certified copy thereof (Sec. 3800, Lab. C.) 76A364c _ HEATING - 'VENTILATING - AIR CONDITIONING - .• 20-0046 DPW'9/88 - .. 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 BUILDING _ tion department. ADDRESS X42, i C' ;, � * (PRINT OR TYPE ONLY) - Date Applicant - - 'LOCALITY • _ NO.. . TYPE OF.APPLIANCE OR EQUIPMENT -FEE CERTIFICATE OF EXEMPTION FROM WORKERS' 'NEAREST - COMPENSATION INSURANCE CROSS ST. _+ 1-1,4-Ll `(Thif SBCfIOd need not becomple}ed'If}h@WOrI(Involved by ABSORPTION UNIT, BTU l+ DISTRICT NO. PROCESSED BY. - ' the permit Is for one hundred dollars (S100) or less.) _ -� ' I certify that in theperformance'of the work for which this AIR HANDLING UNIT, CFM D Permit is'issued; I shall not employ any.Person in any manner_ BOILER,-BTU sc as to become subject to the Workers,COmpensbtion Laws. APPROVALS DATE INSPECTOR'S SIGNATURE ,}Date- ' Applicant COMPRESSOR, BTU - ROUGH :NOTICE TO APPLICANT: If, after'-making this Certificate of, VENTILATION SYSTEM FINAL - �7`/� �m{✓ - . Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,'you must forth- , EVAPORATIVE COOLER i1 �.0 VALIDATION ' s with complyy with such provisions or this permit shall be deem= ed.revoked. - R ,� FLOOR FAU_V_GRAVITY LICENSED CONTRACTORS DECLARATIONBTU 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. _ _ , L ./� v d License Number Lia Class - Poo. O ' ,Contractor -Date - � ❑ • I am exempt under Sea Plan check fee W 8.8P.C. for this reason i d PERMIT ISSUING FEE f / S o O i,`1 Dote: - _ Z I , - - TOTALFEE b _ Signature _ ACC.T.a OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exemptfroom the Contractor's License ► r.j,i)I I 'Law for the following reason (Section'7031.5, Basinesa and NAME - - - • 1 I�G�`_• - Professions Code): - f -} �y�-s j :ADDRESS - '- (I I m Y. 0 I as-owner of the property, or my employees with I A�' 6 f wages as their sole compensation, will do the work and. (.HE"}` 1.tlfl -.the,structare Is not intended or offered for sale (Section- CITY. _ . . TEL. NO. _ 7044, Business and.Professions Code). _ OWNER ' - CHANGE � .I, as owner of the property, am exclusively contracting'- Ed?Al with licensed contractors to construct the project (Sec- MAIL +.tion 7044, Business and Professions Code). _ ADDRESS ) i L 11��'d 5' 1 CONSTRUCTION LENDING AGENCY CITY — iEt. NO. - i I hereby affirm that there is a construction lending agency tor._L f �' , ?1 S 1 All IL:41, the performance of the work for which this permit is issued CONTRACTOR - (Sec. 3097• Civ. C.). . ' ADDRESS - - - -- - Lender's Nome CITY TEL. NO. Lender's Address - I certifythat Ihave read this application and state that the STATE - - - - LIC - - - _ __ _ _ - . PP LICENSE NO. CLASS 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 above-mentioned property for inspecti n purposes., - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap ant or Agent ' Dae/ _ - - - ©s a