HomeMy Public PortalAbout10440 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
I hereby affirm that I have a certificate of consent to self CE-818 (2-80) A p pLICAYIOpFOR PERMIT
insure, or a certificate of Workers'Compensation Insurance„or HEATING-VENTILATING-AIR CONDITIONING
u certified ccoUo�p+y�theieof(Sec.3800(..��L./'--b.Cr.)
Policy No.lvP &�ZL'om pany`�/-roc_ Vim+
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY -
Certified copy E filed with the county buil m tton BUILDING
+'.., e
' deo
rtmCertified
ct FOR APPLICANT TO FILL IN
DateAPPlican[1 m� _ (PRINT OR TYPE ONLY) ADDRESS
_ _ — fie• 11
LOCALITY
CERTIFICATE OF EXEMPTION F'RC.dt JRKERS NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST Y
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. .- CLO
by the permit is for one hundred dollars ($100) or less.) pls"rmcr No. PRocescEo BY U
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ; � 0
permit is issued, I shall not.employ any person in any manner J
so as to become subject to the Workers' Compensation Laws. BOILER, BTU — F
APPROVALS DAT INSPECT R's SIGN TUBE W
Date Applicant - / COMPRESSOR,BTU�a���� f ROUGH e✓ d
N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL "I "ZIP O..d Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOT ERO VALIDATION
with comply with such provisions or this permit: shall be a0
deemed revoked. - FURNACE: FAU_ —GRAVITY_ Q
LICENSED CONTRACTORS DECLARATION FLOOR: BI U_
-
I hereby affirm that I'am licensed under provisions of Chapter HEATER:' SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Bust- WALL
.ness and Professions Code, and my license is in full force and
effect. !!�� ••�� -I
License Numpb�ervT_ s7/3 Lic.Class -�•�j�
Contractor.sCDate
1 am exempt from the licensing requirements as I ama
licensed architect or a registered professional engineer Plan Check fee 25% of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ o
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 IGD 4 4 1,3'A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS •# oos o 08
I, as owner of the property, will do the work and the + +
structure is not intended or offered for sale (Section CITY TEL. NO. 2 0 0 3 Q 5 0
7044, Business and Professions Code).
❑ OWNER jj / yI/ ;o:s o30,50U
I, as owner of the property, am exclusively contracting ( �/�•/s a(le A��e�/_�'_''�'� +
with licensed contractors to construct the project MAIL / O 1, 0_ 3
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY ^ TEL.NO.
I hereby affirm that there is a construction lending agency /
CONTRACTOR
for the performance of the work for which this Permit is /
issued Sec. 3 Civ.C.).
Lender's Name
ADDRESS '
Lender's AddressCITY n 41,gL.NO. 6
I certify that 1-have read this application and state that the STATE '7�7� q LIC. L
above information is correct.I agree to comply with all County LICENSE NO.�J W / CLASS �f
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,mr above-mentioned property for .,
iris er -on purpr s
Signature of P: milt Date -