HomeMy Public PortalAbout10465 LA ROSA DR_Mechanical__ 'WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
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I hereby affirm that I have i certificate of consent to self CE -8'18 (2.80) A Ir I(- L IC A 1 I 01 tl FOR PERMIT n
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING IILJI'
a certified copy thereof(See.3800, Lab.C1) r
Policy No:y"612 ompanl'- a/v L'I - (3'. 7 ,
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the count?t7 bg inspection
`
BUILDING
dznar mef � FOR APPLICANT TO FILL IN ADDRESS
Date.�-� ✓ AppBcan (PRINT OR TYPE ONLY) /O
LOCALITY
CERTIFICATE OF EXEMPTION FR d OR '
RK
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This Section need not be completed if the Woik involved ABSORPTION UNIT, BTU CROSS ST. O
by the permit is for One hundred dollars ($100) Or less.) DISTRICT NO, PROCESSES
1 certify that in the performance of the work for which this AIR HANDLING UNIT;CFM
permit is issued, I shall not employ any person in any manner v d 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
1 APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,8TU_t}_G �J POUGH _ d
N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /�� - �> ?
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. ,
LICENSED CONTRACTORS DECLARATION FLOOR:FURNACE: FAL `/DUGRAVITV_
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 Busi. WALL _
mess and Professions Code, and my license is in full force and -
effect. ,��} q /o
License Number.3�/" /// Lie.Class C.�®
Contractor_Ea(,j--(— Date e9 Z 7 '
❑ I am exempt from Une licensing requirements as lama
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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. 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-
ness and Professions Code): ADDRESS 254 1.5 A
❑ 1, as owner of the property, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY #•° ° ° ° 4 1
7044, Business and Professions Code).
❑ OWNER CC �at,�U'_M E/P✓t COY�o , 2 ° ° 27.00
I, as owner of the property, am exclusively contracting /—a(_L
with licensed contractors to construct the project MAIL 'yin r
(Section 7044,Business and Professions Code). AOORES///5��� ���5 f[/'(/°/aj p E—�bN� ,° e ° `2 7,0 0 5
CITY — __ / TEL. NO. Al4� ^„j(�13 052,7-81
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 3097, CONTRACTOR f 3, Y
for the performance of the work for which this Dermit is
issued (Sec. 3Civ.CJrG r. -
Lendei's Namee ADDRESS
Lender's Address. . CITY 4 1Z —e TE L. NO.
I certify that I have read this application and state that the /r y�� � y -
Pp 'STATE LIC.
above information is correct. 1 agree to comply with all County LICENS- NO. l CLASS ��
ordinances and State law's regulating Heating. Ventilating and
Air Conditioning, and hereby authorize representatives of this. SEE REVERSE FOR EXPLANATORY LANGUAGE
Cnunty to enter p u "'z above-mentioned property for
iu ct�n purpos y
Sign Per .ittt Date C% _