HomeMy Public PortalAbout10403 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION FO la PERMIT �t
I hereby affirm that 1 have a certificate of consent to self CE-818 (2-80)
insure, or a certificate of Workers' Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800. Lab. C.)
Policy No.yp-�p. �;:o m pany$_f_a.A
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND•SAFETY
Certified copy is filed with the count 'but l" r .ir,eection
d}e�parGtme t } FOR APPLICANT TO L ) IN BUILDING
/Dy03 L
Date/�] Applicant - (PRINT OR TYPE ONLV) LOCALITYCERTIFICATE OF EXEMPTION FRO .WIRKNO. TYPE OF APPLIANCE OR EQUIPMENTFEECOMPENSATION INSURANCE NEAREST // }(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. /"� {' @O
CL
by the permit is for one hundred dollars (SI00) or less.) DISTRICT NO.AIR HANDLING UNIT,CFM1 certify that in the performance of the work Inr which this lQpermit is issued, I shall not employ any person in any manner 'so as to become subject to the Workers' Compensation Laws. BOILER, BTU LIJ
Date ApplicantCOMPRESSOR, BTU7ff r� ROUGH APPROVALS DATENOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SVSTEM FINALZ
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU.6�S GRAVITY
LICENSED CONTRACTORS DECLARATION
/ FLOOR: BT� / I
I hereby affirm that I am licensed under provisions Of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code. and my license is in-full force and
effect. 30 `�/ ,0,2O
License Number. J Lic.Class_
jjr 7 /y p
Conlractor�q(,s_ -/- Date / O_�
I am exempt from the licensing requirements as I am a
licensed architect or a registered professionalengineer Plancheckfee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$/
Lie.or Reg.No. Date TOTAL FEE !
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-
nessand Professions Code): ADDRESS _
1, as owner of the property, will do the work and the # 0 0 0 o a 8
structure is not intended or offered for sale (Section CITY TEL. NO. 2e a 3050
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting Fa�'Y /�,ve v_pe11' OY� e o a 3 Q.5 P 5
with licensed contractors.to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS 0 a j� 0.—83
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 /rs / A1b�Ca , firlel
issued (Sec.3097,Civ.C.). Cir' f—e /j
Lender's Name ADDRESS 7�6 'V! �a,_�•�'�✓/'�,
Lender's Address CITY VV" G/ILL.. NO.
1 certify that I have read this application and state that the STATE 0�+7 p LIC. /���✓�/
above information is correct. I agree to comply with all County LCEN
ISE NO. sJ.)��..77 f / CLASS 4
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ente- u' on the above-mentioned properly for
imneelmn pmp,
�® J/Q � .
Signature of Pe'.nitt. Date