HomeMy Public PortalAbout10345 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
1 hereby affirm that I have acertificate of consentto self
CE -818 (2-80) APPLICATION FOR PERMIT
insure, or a certificate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800.11,ab.rf`.)
Policy No.iQ_S(J Kf2'ompany.A�_ale!✓-NC/.
El Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
I Certified copy is filed with the county buil 0 _^ms ectmn BUILDING ��✓
Date (,�� � '�l� - _ FOR APPLICANT TO FILL IN
Date_ Applicant ,_sG(i'��.=� GG!!C^C��[- (PRINT OR TYPE ONLY) ADDRESS
LOCALITY T
CERTIFICATE OF EXEMPTION FR .M♦v ORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /_G rYf
COMPENSATION INSURANCE NEAREST
CROSS ST. 1- - d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED Y U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cc
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 - �1�.r
Date Applicant COMPRESSOR, BTU v?� lN�. APPROVgLS U
DATE I INSPECTOR'S sIGNATORE I
ROUGH WJ N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ^�Q• fid` 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. ..b
deemed revoked. FURNACE: FAUbo- GRAVITY /
LICENSED CONTRACTORS DECLARATION FOOR: BTu
L
I herebv 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. 7 p
License NumberJ�,J�JO�, /_/_ Lic.Class /ao2 Q
Cont ractor, p S /C_ Dete_�_/_/ -05
1 am exempt from the licensing requirements as I 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 FEE $
Lie.or Reg.No. Date TOTAL FEE - 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi.
ness and Professions Code): ADDRESS A 4 4 0,5 A
1, as owner of the property, will do the work and theCITY, TEL. NO. T o'e e - 8
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code).
QOWNER ! _ ,0 IrOYA . .ta a3.O�_JrO
1, as owner of the property, am exclusively contracting Y �!/_ ✓'
with licensed contractors to construct the project MAIL s ,a,o 0 30..5.ps
(Section 7044, Business and Professions Code). ADO RESS _ - — - U�+! - ' t .
CONSTRUCTION LENDING AGENCY CITY =L.NO. .0 8, 1 07 813
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 r
Lender's Address CITY C� TIV_NO.�! G
I certify that I have readthis application and state that the STATE V / LIC. b/97_�[_//r/7
above information is correct.I agree to comply with all County LICENSE NO. DO ��� CLASS lr
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE -
County to enter ,poo above-mentioned properly for
insu,.ct'' n Purpos
_ _ 9ip �3
Signature of P r �i rte - Date