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HomeMy Public PortalAbout10420 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION 1p�p p p� C l� PERMIT 4 I hereby affirm that I have a' certificate of consent to self CE -818 (2-80) A lr Ir L IC PST I O 1 tl 1- O R Ir E R IVY I I �t insure, or a certificate of Workers' Compensation Insurance,ch HEATING-VENT ILATI NG-AIR CONDITIONING �U{ a certified copy thereof(Sec. 3800.Lab. Policy No: -Irs,93�ompanyJ/_a/GF-4I O ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county bt, 1%,ng inspection - BUILDING department /(//1FOR APPLICANT TO FILL IN 7r�I `Q? � �/�OPRKERS' (PRINT OR TYPE ONLY) ADDRESS Dale_ _ - _ Applicant /yLOCALITYCERTIFICATE OF EXEMPTION FRGM 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. AYa�ri O by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. - PROCESS Fav U 1 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 �/�t /J APPROVALS DATE INSPECTO 'SSIGNATURE W Ua[e Applicant / .COMPRESSOR, BTU—/—°r/ �� / ROUGH .' - y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM ? Exemption, you should become subject to the Workers' FINAL �Z�z�' 'V� Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOL-ER Q VALIDATION with comply with such provisions or this permit shall be -EQ© deemed revoked. FURNACE: FAU--� GRAVITY_ E7 - � 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 fall force and effect. y 6 License Number t/�5 �/ Lic.Class_l. _�2 0 Contractor Date Date-7-4>'6- ❑ 1 am exempt fr,m the licensing requirements as 1 am a 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 $ y 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- 4 4 1.5 A ness and Professions Code): ADDRESS ' I, as owner of the property, will do the work and theI # e o s.e . 8 structure is not intended or offered for sale (Section CITY TEL. NO. • ; 7044, Business and Professions Code). //"} 2 0 0 3 0.5 0 OWNER f,_P ha(��•✓ ,oCa ! C'O Y� ❑ I; as owner of the property. am exclusively contracting .o o e 3 Q 5 Q s with licensed contractors to construct the project MAUL � o (Section 7044, Business and Professions Code). ADDRESS 1 .08 1. 0� 8 3 CONSTRUCTION LENDING AGENCY CITY TEL.NO. , 1 hereby affirm that there is a construction lending agencv CONTRACTOR ri .& for the performance of the work for which this permit is v qL yea//N issued Sec.3097,Civ,C.). - Lender sName ADDRESS ' Lender's Addressv q / CITY A/ya T NO.g6/ S/�y ' I certify that I have read this application and state that the STATE ✓ /y CLASS G' Q above information is correct. I agree to comply with alt County LICENSE NO. _7 ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Co4gna1J.'ni4_wf_Pm�4.e tttr up/., le above-mentioned property for Date - _