HomeMy Public PortalAbout10325 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
ip�p p •y p� FOR
1 hereby affirm that I have a certificate of consent to self CE -818 t2-80) A 1'- Ir L IC A 1 �Q 1 tl r O R PERMIT
insure, or a certificate.of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified Icopy thereof(Sea 3800 Lab C11 J
Policy No7%ezz'ompany_S_�6 f��u �l ;
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
}� Certified copy is filed with the county eWG)RKERS'
FOR APPLICANTTO FILL IN - eUf LDING
( depart a t. ADDRESSDate--r ApplicantLsyaP� _ (PRINT OR TYPE ONLY)NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �T - _cCEATIFICCO E EXEMPTION FN. E �P•
COMPENSATION INSURANCE NEAREST y
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. rdLo N O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROLES ED BV
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued. 1 shall not employ any person in any manner o / 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE U
L �sO W
Date Applicant.. COMPRESSOR, BTU 6 e J ROUGH y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL' tim[ ?
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: FAU40D GRAVITY
LICENSED CONTRACTORS DECLARATION !/ FLOOR: BTS l
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. ^ JVT n
License NumbrsJLic. Class
Contractor.
-7 Date -' /= 0, >
❑ I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan cheek fee 25% Of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEES t
Lic.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 -2 4.4'0.3 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS # e le e,a e;8
❑ I, as owner of the property, will do the work and the CITY TEL. NO. .21° ° 3050
structure is not intended or offered for sale (Section '
7044, Business and Professions Code). °I° ° 3 0. 6 C)csi
OWNER
F-1 //p lir �I�/�' .
I, as owner of the property, am exclusively contracting �!_L a V_C'�✓r v , ,O 0,_8.3 .
with licensed contractors to construct the project MAIL - - '
(Section 7044, Business and Professions Code). - ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR)&/U--
�
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address [ST
Y // TE_. NO.
/T -usa X6.9 3//y
I certify that I have read this application and state that the ATE 0 `/' LIC.
above information is correct I agree to comply with all County ENSE J. [/�� 7 CLASS v X20
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ente7l upon the above-mentioned property for
n^-ecYon purer '� .
7 �d
Signature of Jr
mitt—ate -