HomeMy Public PortalAbout10410 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
1p 1p py p� 1�- PERMIT y
I hereby affirm that I have a certificate of consent to self CE-818 (2-80) A l� If— L IC A 1 I O 1 tl f" O R Ir E R IVY I 1
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATI PIG-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab. Cy.)
Policy �'
No.yB�Q3 .ompany—J_ a/G�_r vd,
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the cild a^ Ispecti I
f'
depart—cos� FOR APPLICANT TO FILL IN BUILDING
DDRESS /otilo �a IQQs_a
Date7? T_a Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST t�
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. N 1"..a �Al O
by the permit is for One hundred dollars ($100) or less.) DISTRICT NO. / PRO.EISEDly Q
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM_ �/V (/
permit is issued, 1 shall not employ any person.in any manner O 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
o APPROVALS DATE INSPEC R'S 5I NATURE
Datew
Applicant t COMPRESSOR, BTU_'412J00
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM ! Z
Exemption, you should become subject to the Workers' FINAL
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: FAD_ O_ GRAVITY_l� O
LICENSED CONTRACTORS DECLARATION F FLOOR: BTJ
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.
License Number p_a/_Z pT_r Lic. Class—a—_
Contmctor�/�t(_,g/e Date �Q_ !C
I 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-
inessandProfessions Code). PERMIT ISSUING FEE $
Lic.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-
ness and Professions Code): ADDRESS
❑ 1, as owner of the property, will do the work and the4 3 9 9 A
structure is not intended or offered for sale (Section CITY TEL. NO. z ,
17044. Business and Professions Code). # • o ° ° o
1:1 OWNER
, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL ,2 ° ° 30.60
(Section 7044, Business and Professions Code). ADDRESS '
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 3 O.6 O
1 hereby affirm that there is a construction lending agency /,//�., / B,.�. O'8,3
for the performance of the work for which this permit is CONTRACTOR /is_ /�°�•I/KlT z .
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS ��6 /•r �Q �ZApI//�!
Lender's Address - CITY (((/iL. NO. 7N f s„y
I certify that I have read this application and state that the STATE �•jusa LIC. /�
above information is correct. I agree to comply with all County LICENSE NO. r),�/ 9 CLASS y ��
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter up n above-mentioned properly for
iusnecron purpos s.
eignat ure of p .dtrDate -
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