HomeMy Public PortalAbout10335 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION I/^ gYlOpt COIp PERMIT
�p[i �4
I hereby affirm that I have a' certificate of consent to self CE-818 (2-B0) A Ir Ir ` C A / 1 tl r R I(- E M Y
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3900,Labb.Cy) C
Policy No.�OSss7��om pany_�/-�/_(/(✓�.�
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county.tourr n, ins--ction - FORAPPLICANT TO FILL IN BUILDING
departme=f7r' � q __ ADDRESS /l7r�v` ,�ajeas�
Date.�-L97Applican1 (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROL,Wo.RKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST /I }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. ` e O
by the permit is for one hundred dollars (5100) or less.) - DISTRICT NO. PROCESSED BY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM� ^ /L
permit is issued, I shall not employ any person in any manner f„/ O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU ~
lAPPROVALS DATE I INSPECT^R'S SIGNATURE W
Date Applicant / COMPRESSOR,BTU-19—V ROUGH ��� _ -�� taq
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �d' .-/`�' I,��.Ls.J 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: FAW 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 Busi- WALL
ness and Professions Code, and my license is in full forceand
effect. 7 Cj' (�
License Numbbetet_�V�!— Lia Class_f. Z 6QQ 7
ContractorlG.=(/-s/ i� Date
❑ I am exempt train 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). PERMIT ISSUING FEE $
Lie.or Reg.No. Date TOTAL FEE r-
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 �9 4 4 a 4 A
❑ L as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO. # oto e e a 8'
7044, Business and Professions Code). /^/ ,,t - 2 e s
❑- I, as owner of the property, am exclusively contracting OWNER—F-,-f_e
�a��y/� - eV� �DY-p ; J�,JOO
P`with licensed contractors to construct the project MAIL / �/ ��// / ,e o -,3,0,5.0 m
(Section 7044, Business and Professions Code). ADDRESS r t
CONSTRUCTION LENDING AGENCY CITY TEL.NO. OR 1:0-83
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sec. 3097.Civ.C.).
Lender's Name ADDRESS 641- Q`e
Lender's Address CITY �a IL.NO.�/��-s�/[/
I certify that I have read this application and state that the STATE �G LIC.
above information is correct.1 agree to comply with all County LICENSE NO. 1,j(/U7 V� 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 of in the above-mentioned property for -
in^ ecr'an Partin,
Signature of P mute. Date