HomeMy Public PortalAbout10430 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
l�1p py p� p PERMIT
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I hereby affirm that I have a certificate of consent to self CE-818 (280) A r If— L IC A 1 I O 1 Al FOR Ir C R M I 1
insure. Or aCertificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified�c/opppy pthe�reof(Sec. 3800c,Lab.C.) [' J�/
Policy No1f/915 -2Company.rS�a XE_I ZLa_
❑ Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county bi ,P.n' spection BUILDING
+� depart•^en yr-.r.n � FOR APPLICANT OR NTTO LY) IN ADDRESS •IOJ���a/�D.S�j
Uate�=� V Applicant C-LCL.. h (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION P'RI .d NOR KERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE •/_Y_
COMPENSATION INSURANCE NEAREST ^ ( >_(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. T 0
by the permit is for one hundred dollars ($100) or less.) - DISTRICTNO. PROCESSED 6Y U
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I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM—
permit rl 2
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
_ APPROVALS DATE INSPECTOR'S SIGNATURE (J
Date Applicant _ COMPRESSOR,BTU_y_ UJI
dao ROUGH —J- �/_ y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL ` Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLERQ�rj .� VALIDATION
with comply with such ,provisions or this permit shall be LL !/r/
deemed revoked. / FURNACE: FAU.e�— GRAVITY j
LICENSED CONTRACTORS DECLARATION FLOOR:_ BT i
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. e� /7 d
License Number_J �l Lic. Class_f+ -
Convector F�G[.S- C Date
ED I am exempt f_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-
iness and Professions Code). //
Lic.or Reg.No. - Date TOTAL FEE
g 4-4 1.4 A
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
r
I hereby affirm that t am exempt from- the Contractor's NAME I
License Law for the following reason (Section 7031.5, Busi- 4o
Rees and Professions Cade): ADDRESS .2j, /` 3 O.5.0 -
El 1, as owner of the property, will do the work and the 4e•e o 30605
structure is not intended or offered for sale (Section CITY TEL. NO. ,
7044. Business and Professions Code). O 0.ER •�� 0—813
OWN
I, as owner of the property, am exclusively contracting FbJ fir-/�
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
issued (Sec. 3097,Civ.C.). F- YYY /Yf
Lender's Name ADDRESS�r
Lender's Address CITY r{./ // rY `TE L(/7NO. rd P sf�y
r9U_.$�
1 certify that I have read this application and state that the gTATE J _ LIC. ,
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter u'on the above-mentioned property for
iu�^ec ton purpo e.
Signature of P .ro a Date - _