HomeMy Public PortalAbout10315 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
I�IIS 1 '� p 'Y I O pl ICo Ip PERMIT ly LI 'F
I hereby affirm that I have a certificate of consent to self CE-818 (2-80) A If" Ir L P'i 1 1 V r R Ir R IVY f
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified cLoypv� thereof(Sec. 3800,Laa..b.1C.)
Policy No.7�S027ZCom pony�/f3
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
1[� Certified copy is filed with the county b� -1d .r ,�. pection BUILDING Q
depart—en, FOR APPLICANT TO FILL IN goDREss
Date?�/`QS. Applicant% EA (PRINT OR TYPE ONLY)
LOCALITY rLo.�yr��E
CERTIFICATE OF EXEMPTION FRGM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 7
COMPENSATION INSURANCE NEAREST
CROSS ST. IL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU A r O
by the permit is for one hundred dollars ($100) or less.) - msTRlcT rvo. PRocESS BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Ir
permit is issued. I shall not employ any person in any manner _ 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
99 OO J APPROVALS DATE I INSPECTOR'S SIGNATURE L)
Date Applicant ` COMPRESSOR,BTU_J_� f/ T ROUGH �'..�- y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ! l`J—OIZZ Z
Exemption, you should become subject to the Workers' '
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLFiRR VALIDATION
with comply with such provisions or this permit shall be ``
deemed revoked. FURNACE: FAU.(J0_ .GRAVITY_
LICENSED CONTRACTORS DECLARATION / FLOOR: BJ
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. qq 77 GG - n
License Number_V_�J�7 Lie.Class it G-D0 S
Contractor-t4— e—A/ Date
I am exempt fn m the licensing requirements as I am a
licensed architect or a registered professional engineer Rofabove.
acting in my professional capacity (Section 7051, Bus-iness and Professions Code).Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS 4 4 0.2 .A
ED 1, as owner of the property, will do-the work and the `
CITY TEL. NO.
structure is not intended or'offered for sale (Section # eIo 0 o,e
7044, Business and Professions Code). / ,/ /} 21-,- 3
i, as owner of the property, am exclusively contracting OWNER y.. ✓eM y Ys / �Y�r • 0� J O
with licensed contractors to construct the project MAIL lr Ion,oj 0,5 O. .
(Section 7044, Business and Professions Code). ADDRESS o
CONSTRUCTION LENDING AGENCY CITU - TEL.NO. O B,�1 01-83
I hereby affirm that there is a construction lending agency `
for the performance of the work for which this permit is CONTRACTOR t/ //
issued (Sec. 3097,Civ.C.). FFFF���
Lender's Name ADDRESS 717 �n/r _�dV/C�
Lender's Address CITY y'��Ue�Gi�1177� TCL. NO.'�Gf9 ��y .
I certify that I have read this application and state that the STATE �7 �•q /� LIC
CLASS GCi ��0
above information is correct. I agree to comply with all County LICENSE NO.aJµ-)V
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to er er the above-mentioned property for
incp, tion put. os
k
Signature of .rm� .ee Date