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HomeMy Public PortalAbout10300 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION �Olf� PERMIT I hereby affirm that I have a certificate of consent to self CE -818 (2-80) R E R M insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a Certified copy thereof(Sec.3800. Lab.C.) �L�L^++• 11 Policy No.7_tfX6.FZCompany Xfd_fLI Certified copy is hereby furnished. ' COUNTY OF LOS ANGELES BUILDING AND SAFETY 19 Certified copy is filed with the couNJM- I .'nspeclien BUILDING / IanarfGe�- FOR APPLICANT TO FILL IN ADDRESS /030 Cl/Ca JPOS2 Date�E 7 Applicant(. 4^_ (PRINT OR TYPE ONLY) LOCALITY /e,�•h /`p / f'� CERTIFICATE OF EXE PTiON FORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 7 �a COMPENSATION INSURANCE CROSS ST.NEARESTa (This section need not be completed if the work involved ABSORPTION UNIT, BTU O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY U 1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Q permit is issued. 1 shall not employ any person in any manner O so as to become subject to the Workers' Compensation Laws. BOILER, BTU H APPROVALS DATE ' INSPE 'S SIGNATURE W Dale Applicant '< COMPRESSOR,BTU 7 )�d ✓ ROUGH ��r y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM/ FINAL -Z - _v 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 ©a - - deemed revoked. FURNACE: FAU.tO-OGRAVITY_ LICENSED CONTRACTORS DECLARATION , FLOOR: B7J / 'p •-� I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. / �,-7 License Numb��ers7q'72J- -`�— Lia Class Contractorje-�-X/ Date I am exempt fArn the licensing requirements as I am a licensed architect or a registered professional engineer rcheckfee above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). ERMIT ISSUING FEE $ l Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;2440.OA I hereby affirm that 1 am exempt from the Contractor's NAME # 0 0 0 0e,8 License Law for the following reason (Section 7031.5, Busi- ' , , , , , ness and Professions Code): ADDRESS 2o e 3 Q 5 Q F1 1, as owner of the property, will do the work and the CITY TEL. NO. II - structure is not intended or offered for sale (Section e o o 30,5 0 5 7044, Business and Professions Code). pp^/�/) ❑ OWNER G 'Yk�dela iarN r OYP 0a.11, 0-83 I, as owner of the property, am exclusively contracting di_-/�' ) with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1 hereby affirm. that [here is a construction lending agency �O.T /e � for the performance of the work for which this permit is CONTRACTOR yr _ A issued (Sec. 3097.Civ.C.). Ile?I Lender's Name ADDRESS nab Lender's Address I certifythat I have read this application and state that the CITU _ _Jsa ' NO9�9-5/�7 pp STATE /� LIC. above information is correct. I agree to comply with all County LICENSE l s l- r/ CLASS l.• f ordinances and State laws regulating Heating. Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPIyANATORY LANGUAGE County to enter v-r- I Ie above-mentioned property for inspec ion pure' ep�� Signature of P mi -.e Date If