HomeMy Public PortalAbout10330 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
Ip 1p p y p� l� 1� PERMIT p(I y
I hereby affirm that I have a' certificate of consent to self CE-818 (2-80) A lr I� L IC A 1 I O 1 tl r O R Y- E R M I 1
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certifiedcopy thereof(Sec3800.1ab0
Policy No,105pjiCompany�ww ..?) UK
.
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�v Certifiedcopy is filed with the county'bui'Jig` action BUI LOING n
deparr•nec� FOR APPLICANT TO FILL IN ADDRESS /0,K?0 . .?'0 O0 S
Datelti�_ Applicant_ _ IPRINT OR TYPE ONLY)
LOCALITY 1
CERTIFICATE OF EXEMPTION VR. JR KE RS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE !,�-p7 -/,, 6144
COMPENSATION INSURANCE NEAREST CROSS ST. ��� a
(Phis Section need not be cOmple[¢d if the Work involved ABSORPTION UNIT, BTU O '
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO, f✓ PROCESSED By O
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM—
permit permit is issued, I shall not employ any person in any manner _ O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU — - H
APPROVALS DATE INSPECTOR'S SIGNATURE (J
W
Date Applicant / COMPRESSOR, BTU_ Qt�t7 �� ROUGH �r aa� raj)
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 Q�
deemed revoked. FURNACE: FAU��GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU /
I hereby affirm that I am licensed under provisions Of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Professions Code, and my license is in full force and
effect. p
License Number 6b-�l If_ Lii:. Class_C�
//t n
Contmctor,Ff1� -Date_7`49 O 3
❑ f am exempt from the licensing requirements as I 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). PER ISSUING FEE $
Lie.or Reg.No. Date TOTAL FEE Ij '
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME z 4 4 �.() A
License Law For the following reason (Section 7031.5, Busi- - - -
nessand.Professions Code): ADDRESS -
❑ I, as owner of the property, will do the work and the -
CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ///..�..++• 2 `j�'Jr Q
❑ OWNER �' a✓� �✓ _
1, as owner of the property, am exclusively contracting �(]_� /v D-_ � OY ,o�ere 30 500
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS & 'p;8 3
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency ///��' �r
for the performance of the work for which this permit is CONTRACTOR 1.- J f L!/ - yGpa Y.'M
issued (Sec. 3097,Civ.C.). �j 6-V 11"« 4.� 1,
Lender's Name ADDRESS//ll /oZ 4' 1VJ
Lender's Address CITY. �/ • �E L. NO.
TE
I certify that I have read this application and state that the STA (Yrs/ AP�J f/ CLASS
above information is correct. I agree to comply with all County LICENSE NO.
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter ,on I+e above-mentioned property for
insn�rp se
Signature of P mith Date