HomeMy Public PortalAbout10455 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
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I hereby affirm that I have s certificate of consent to self CE-818(2-80) A Ir r L IC PY 1 I O 1 tl f O R PERMIT
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insure, or a certificate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
u certified copy thereof(Sec. 3800,Lab.C.) J'
Policy No. Com pan
�bi?—F!Ns COUNTY OF LOS ANGELES /� / BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county b/1,eXpispect ion FOR APPLICANT TO FILL IN BUILDING
denartmenJtt. nD� ,� ADDRESS '}/S'i9�
Dates' 7"f'J� Applicant " - (PRINT OR TYPE ONLY) /� Pt-0
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE'
COMPENSATION INSURANCE NEARESTCROSS ST. t✓�� d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars (S100) or less.) DISTRICT N0. eSOCESSrD e- U
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM J r s pcc
permit is issued, I shall not employ any person in any manner G,000 O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU LL H
Dale Applicant ./ COMPRESSOR, BTU-LRI O ROUGH APPROVALS '7D/AT_E�l/ INSVECTon's SIGNATURE W
V QI
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ?
Exemption, you should become subject to the Workers' 6 ZZ'
Compensation provisions of the Labor Code, you must forth-
with provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
with comply 1 with such QBCJ
deemed revoked. FURNACE: FAU� GRAVITY—
LICENSED
RAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR: B' U Q
I hereby affirm that 1 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. 9 _ f, /r
License Numbber_O d''S 3/ / Ic.Classss_(/_'Z �Vj
Contractor17
E_C6,,/,Dale�? 7 C/�
1 am ezempI from 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). PERMIT ISSUING FEE $
Lie.or Reg.No. Dat¢ TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from- the Contractor's NAME -
License Law for the following reason (Section 7031.5. Busi- 215 4 Q 4 A'
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the # °,°�° ° 4 1
structure is not intended or offered for sale (Section CITY TEL.NO. 1
7044, Business and Professions Code). ///------•• 2:-'-2 7,0 0
OWNER ey,
❑ {.. •r / �
1, as owner of the property, am exclusively contracting / a/ �{3✓'-°4:( eO Y� 27,0 0�
with licensed contractors to construct the project MAIL -y�� / J
(Section 7044, Business and Professions Code). ADDRESS ///p/ AVt C` / bN
0527-81
CITY
CONSTRUCTION LENDING AGENCY Arc d_ ./_8— TEL. NO.$, "'l BO,j
I hereby affirm that there is a construction lending agency ,1
for the performance of the work for which this permit is CONTRACTOR
issued Sec. 3097.Civ.C.). Pd rT
Lender's Name qDD RESS
Lender's Address CITY L.NO.
I certify that 1 have read this application and state that the STATE 30-5�3�9• GLASS
above information is correct.I agree to comply with all County LICENSE NO. /
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County tocote• u11o' t . above-mentioned property for
ins(oDe/cJ,npure y
Signature of Y.mitt ,; Date