HomeMy Public PortalAbout10425 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
1p 1p1 ppy p� I� PERMIT I hereby affirm that I have a' certificate of consent to self CE -818 (2-80) A P P L IC A 1 I O N FOR r E Y' M I
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab.CC..) J '
Policy No.�fsk aZ2'ompany_S!!/_��UNC7.—
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county bulb' I 1, ,3 tion FOR APPLICANT TO FILL'IN BUILDING
depart men�.r ADORE SS Ot$
Date_?��_I`r_I J- APPlicant.. _ ___ (PRINT OR TYPE ONLY)
///JJ/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Y �r'�/
CERTIFICATEOM E EXEMPTION FR N WOKKE RS' ���...+++
COMPENSATION INSURANCE NEAREST T
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST.
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCES I BY U
I certify that in the performance of the work for which this AIR HANDLING OLING UNIT,CFM �� , 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 ~
' 1j,� APPROVALS DATE INSPECTOR'S SIXTURE W
Date Applicant J COMP RESSOR,BTU=]_ �0O / C
ROUGH � C� N
,NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r6..- 1 `t- z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER Q VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU.O�' 0eGeV ITY_�Q
LICENSED CONTRACTORS DECLARATION FLOOR: 87,z -�
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. //�I� /'►
License Numberrr3/.L7-?/9 Lie.Class
Contractor- p _�_ Date
❑ I am exempt rr om 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-
EE ISSUING FEE $ / _ �
loess and Professions Code). /
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
w
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 the z 4.4.1.0 A
structure is not intended or offered for sale (Section CITY TEL. NO.
8
7044, Business and Professions Code). # o o s o a
I
❑ OWNER /
I, as owner of the property, am exclusively contracting F./ l h_e`a VC'� G�U� OY�- .2 • a 3 0,5`0
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS �o Io a 3 0.5 0
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency /�//� y)- 0 8 1, 8 3
for the performance of the work for which this permit is CONTRACTOR yea
issued (Sec.3097,Civ.C.). 6 914 O soy(/•' eft.
Lender's Name ADDRESS^7�� r �tlYl�a !/C
Lender's Address CITY - T-L. NO.Q4y�',-S�//4Y
I certify that I have read this application and state that the STATE / f C ASS /
above information is correct. 1 agree to comply with all County LICENSE ..0. 0V
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
it), ec-ion purp, es 01 -
Signature of!' ,mi ee Date _ _'