HomeMy Public PortalAbout10220 LA ROSA DR_Mechanical__ 364C
WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to*self -
insure, or a certificate of Workers'Compensation Insurance,of HEATING-V ENTILATING-AIR CONDITIONING
r' dq t er.of See 800, 1 ! C ` �,
COUNTY OF LOS ANGELES - �' ` BUILDING AND SAFETY
LD
fied copy is hereby furnished. . - -
Certified copy is filed with the county Idi tg.: s tion - BUILDING (�
tm /1/-p), FOR APPLICANT TO FILL IN gDOREgsaVt_ _ I
APPiicant 1 (PRINT OR TYPE ONLY) -
LOCALITY T
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. - 0
by the permit is for one hundred dollars (SI00) or less.) DISTRICT NO, PROCESS, By ,. V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM l� '¢
permit is issued, I shall not.employ any person in any'manner //// d qa ,G O
so as to become subject to the Workers' Compensation Laws. / BOILER, BTU 4-440 .0 - I_
APPROVALS DATE INSPECTOR'S SIGNATURE IU
Date Applicant COMPRESSOR,BTU ROUGH -30- `: y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM - FINAL . Z
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
deemed revoked. - - FURNACE: FAU— GRAVITY_
LICENSED CONTRACTORS DECLARATION F BTU
I hereby affirm thet•.I am licensed.under provisions of Chapter HEATE USPENDED UNIT
9 (commencing with Section-7000) of Division 3 of the Busi- ALL
ness and Professions Code, and my license is in full force and
effect.
Licensee Number LClas-S -
Conlr: •nt a
1 am exempt from the licensing requirements as 1 am a - -
licensed architect or a registered professional engineer Plan check fee 25%Of above.
acting in my professional capacity (Section 7051, Bus.
iness and Professions Code). PERMIT ISSUING FEE $ '
Lie.or Reg.No. Date TOTAL FEE a7
HOME OWNER-BUILDER DECLARATION PLAN CHECK
APPLICANT -
1 hereby affirm .that I am exempt from, the Contractor's NAME ,I,I w
License. Law-for the following reason (Section 7031.5, Busi- "` )))--Ami---Y--YY-----
ness and Professions Code): ADDRESS (�,_ 6 Z-,+,-
❑El
1, as owner of•the property, will do the work and the pry a'87.2'A -
structure is not intended or offered for sale (Section CITY - ��F' f't��TE L. NOxa, �Z / t
7044, Business and,Professions Code). 41)
OWNER
1, as owner of the property, am exclusively contracting /� 2 ere 27.0 0
with licensed contractors to construct the project MAIL f./r��— I�{�{�
(Section 7044;Business and Professions Code). ADDRESS E
_l�y_L '-1Fy:1U_ S
a e'e 2i7 0 U6
- NO. '
CONSTRUCTION LENDING AGENCY - O 2 1 81
1 hereby affirm that there is a construction lending agency '�/-�-�,f '
for the performance of the work for which this permit is �� ` _
Issued (Sec. 3097,Civ.C.). -1 - .
Lender's Name Lender's Address ' - TE1 certify that 1 have read this application and state that the above information is correct. 1 agree to comply with all County CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE -
ounty [o enter upon [he above-mentioned Property for ,
iI p coon purposr�. _
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