HomeMy Public PortalAbout10320 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
1�(p /+ q y p� I� l� PERMIT p(l 4
I hereby affirm that I have a' certificate of consent to self CE-818 (2-80) A If— Ir L IC A 1 I O 1 tl f O R Ir E R IVY I 1
insure, or a certificate of Workers'Compensation Insurance,04 HEATING-VENT ILATI NG-AIR CONDITIONING
a certified copy thereof(Sec.3800(1�1, b. .) ((�'+'
Policy No.f V,5 Sg Z%,ompanyJVa/�I_ioJ.V_a
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
X Certified copy is filed with the c40;�Pecfion FOR APPLICANT TO FI LL IN BUILDING d�a
department. ADDRESS
Date Applicant_ - _ (PRINT OR TYPE ONLY) LOCALITY �e..�,� �'� ti
CERTIFiCATE OP E%EM1IPTIONKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE e0�%{/rry
COMPENSATION INSURANCE NEAWEST
CROSS ST. Ay �N d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU
by the permit is for one hundred dollars (5100) or less.) DISTRICTNO. PROCESSPD By L)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM y� (_J/ BIC
permit is issued, I shall not employ any person in any manner e1 - 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
q O /7 APPROVALS DATE INSPECTOR'a SIGNATURE W
Date Applicant ` COMPRESSOR, BTU— r+" r_(_� a
ROUGH r-' y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL „C.1 `' 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: FAU1D/DGRAVITV—
LICENSED CONTRACTORS DECLARATION FLOOR: BTU -"
I hereby affirm that 1 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. ppm�t1`` U
License Num/bee,..J_Wn Z ! Lic. Class_C 01O p
Contractor-�i.[!ff
❑ 1 am exempt din 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 FEES
Lie.or Reg.No. Date TOTAL FEE -
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 24 41• 1 A
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO,
o 0 • • 8
7044. Business and Professions Code). _❑ / //� Q o o.3 O.5 O OWNER r /� V�N D�I�• I.OY�• , .
I, as owner of the property, am exclusively contracting
with licensed contractors to construct file project MAIL 3,0,5 n
(Section 7044, Business and Professions Code). ADDRESS 1
CONSTRUCTION LENDING AGENCY CITY d TELL. NO.f/ ,� a 1,0.—813
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CON TRACTOR
issued (Sec.3097,Civ.CJ.
Lender's Name ADDRESS
Lender's Address CITY TEL.NO. _
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon above-mentioned property for
iusoect+on pur pas, '
Signature of Pe ,.Atte Date -