HomeMy Public PortalAbout10708 LA ROSA DR_Mechanical__ .-WORKERS'COMPENSATION DECLARATION G (•L//p APPLICATION FOR PERMIT
},'i.'riereb"y affirm that have o certif;cate,of consent to self 1, A
insure, or a certificate of Workers'Compensation Insurance, j6A364C ly HEATING - VENTILATING - AIR CONDITIONING
or a7ZrOlf7d8 crogy�thereof (Sec 38008 Lob. C.)Und
23 F 76ABIB(REV. 10/81)
Policy No. Company
Certified copy is hereby furnishe COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th co ullding inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 10708 LaRosa
Date/8/89 Applicant LOCALITY Temple City'
NO. TYPE OF APPLIANCE OR EQUIPMENT .FEE .
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST .
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work I v ved by ABSORPTION UNIT, BTU Ins*Rini NO. vl77SED BY
the permit is for one hundred dollars (5100)or le .)
I 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
so as to become subject to the Workers Compensation Laws. BOILER, BTU //��-, APPROVALS DATE INSPE OR'S SIGNATURE
Date Applicant COMPRESSOR, BTU _ CD ROUGH
i
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINALr '
Exemption, you should become subject to the Workers' _
4 4
Compensation provisionsof the Labor Code, you must forth- EVAPORATIVE COOL R I r AL DATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU iY- ID tp
LICENSED CONTRACTORS DECLARATION FLOOR U ((//
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDEDUNIT_(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. �" G
ZS O
License Number 475226 tic. Class C20 - V
oe
Contractor Env. Eng. Dates/8/89 0
❑ i am exempt under Sec. W
Plan check fee d
B.BP.C. for this reason'
Daie: PERMIT ISSUING FEE $ ID Sb z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Low for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended ar offered for sale(Section ---- r,-.
7044, Business and Professions Code). . - - 42. 5
❑ OWNER Joel Mendez -
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 42 - 75
CONSTRUCTION LENDING AGENCY CITY Same TEL. z :"
1 hereby affirm that there is a construction lending agency for
— ^'-=��
the performance of the work for which this permit is issued CONTRACTOIEnvironmentl Engineering
(Sec. 3097, Civ. C.).
Lender's Name -
ADDRESS 601 N. poplar
CITY TEL. NO. c ....,• �°[I%:' 'i
Lender's Address ISS—
1494
S 475226 C20 �' i';1h: L•
I certify that I have read this application and state that the LICENSE NOCLASS -
above information is correct. I agree to comply with all County
ordinan s d State laws relating to building construction,
and hi
eby ut orize representatives of this County to enter
up n e m tined property for ecti n urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ap'p'licant.&.1
ate -