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HomeMy Public PortalAbout10405 LA ROSA DR_Mechanical__ Fhj WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION GI hereby affirm that I have a certificate of consent to self CE-818 (2-80) pp P P L IC Ay I Q pC R PERMIT E MIy insure, or a certificate of Workers'Compensation Insurance,o"r HEATING-VENTILATING-AIR CONDITIONING a certified copy Fttherreeof(Sec.3800�.{{L/aa.b...C.) jam' j Policy No.W.0-72CompanyC - ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY Certified co y is filed with the county buy' t ection dep)artmen,p �� FOR APPLICANT TO FILL IN ADDRESS Date��/—�= Applicants _ _ _ _ (PRINT OR TYPE ONLY) LOCALITY le t✓'�r¢y CERTIFICATE OF EXEMPTION FP iM 10RKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEENEAREST VVV COMPENSATION.INSURANCE CROSS ST, r7�' �+� IL (This section need not be completed if the work involved ABSORPTION UNIT, BTU O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES£ By U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM O CC O permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. - BOILER, BTU (— t' APPROVAL$ DATE INSPECTOR'S SIGNATURE W Date APPhcan[ / COMPRESSOR, BTU'] �p O /O ROUGH @J y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL ,y Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLbR VALIDATION with comply with such provisions or this permit shall be �1_ Q�U deemed revoked. / N - FURNACE: FAU GRAVITY /I —� LICENSED CONTRACTORS DECLARATION FLOOR: BTU v _ 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 Codg, and my license is in full force and effect. ^!) cc License Num/beer.{�!�(h_/7J v / Lic.Class.C`p�U Contractor-(C�j/(/��_ Date ❑ I am exempt 4-am 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. PERMIT ISSUING FEE $ iness and Professions Code). Lic.or Reg.No, Date TOTAL FEE 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 ❑ 1, as owner of the property, will do the work and the CITY TEL. NO. z 4,4 0.8 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). r /� #,o e e e e 8 OWNER W ❑ far_r_l�av��✓_/�evr C'c� ' I, as.owner of the property, am exclusively contracting 2l-'-'3'0.5'0 with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS ��'� 030,50 CONSTRUCTION LENDING AGENCY CITY TEL. NO. _ I hereby affirm that there is a construction lending agency O a,•�'�Q-8.3 for the performance of the work for which this permit is CONTRACTOR��S ©/fir ••FNCa> �(,(� issued(See.3097,Civ.CJ. r Lender's Name ADDRESS/��9 b N� Leader's Address CITY /41T— TEL./NO.?4.f— I certify that I have read this application and state that the STATE I ✓ ^J1r7�G LIC. ^ ✓��7 above information is correct. I agree to comply with all County LICENSE NO.yJ V J 7 CLASS 1. — ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to ent, rpon the above-mentioned property for in-'c' on purp e• Signature of Pr .nit _ Date