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Home My Public Portal About10415 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C IC PY 1 I O 1�7 I-O Y-•i PERMIT I hereby affirm that 1 have a certificate of consent to self CE -81812-801 insure, or a certificate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec. 3800,Lab. ) cM Policy No J_I�Fp_39_Orr pang ��AG'LVOFI Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county bu di y .us :coon BUILDING .•�• departGmentt , FOR APPLICANT TO FILL IN ADDRESS /toa�os� Date�'�y em,Applicant _. _ _ (PRINT OR TYPE ONLY) GiJ LOCALITY fC C/ ¢� CERTIFICATE OF EXEMPTION FRf :I WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE r7n� COMPENSATION INSURANCE NEAREST CROSS ST. rde� d (This Section need not be completed if the work involved ABSORPTION UNIT, BTU— O by the permit is for one hundred dollars (5100) or Iess.) mSTR ICT NO. PROCESSE BY t.,1 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner - / .> J O so as to become subject to the Workers' Compensation Laws. BOILER, BTU T RI— J/�t APPROVALS DATE INSPEC 'SS1GNATURE W Date Applicant f COMPRESSOR,BTU_7IX/ -� ^'� y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SVSTE M/ FINAL ROUGH 0 �' 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 //�� OAU deemed revoked. FURNACE: FAUp� 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 farce and - effect, License Numbb/e�--r par? Lie.Class—C=1 _s v� Contracior ,� �_ Date I am'exempt fi rm the licensing requirements as I am a e 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 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT z440,9A 1 hereby affirm that I am exempt from- the Contractor's NAME 8 License Law for the following reason (Section 7031.5, Busi- nessand Professions Cade): ADDRESS 2 e - 30, 50 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TE L. NO. so•o 030,505 7044, Business and Professions Code). n ' ❑ OWNER U� (•t O'T-yp , �D 1 0;-8,3 I, as owner of the property, am exclusively contracting U r with licensed contractors to construct the project MAIL .(Section 7044, Business and Professions Code). ADDRESS 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 �r /, /y/c � issued (Sec. 3097,Civ.C.). Y Lender's Name - ADDRESS �2 2 Lender's Address CITY A7C4.-S� T__.NO.r516 ��y 1 certify that I have read this application and state that the STATE / 7 LIC. above information is correct. 1'agree to comply with all County LICENSE NU. OSy�� Y CLASS C-�t�Q ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to cote r ion the above-mentioned property for ins�ec 'on purp� Signature of P mi'y��a��s�Date .