HomeMy Public PortalAbout9143 LA ROSA DR_Mechanical__ , n p ,yam �� nn �p �
l kK�RS'COMPENSATION DECLARATION CEA 818 C(2.80) A P P C AT U O u� FOR PERM M
I hereby affirth that I have a certificate' of consent to self I ,
insure, or a certificate of Workers'Compensation In tote,or —T—_ 1�1(E�1TII�1G-V WTIL -TING-AIR CONDI i�Ytl�
�frti�d'opa-yeoe�fie� -
Policy No. C�mpan�
Certified copy is herepy furnished. �a — COUNTY,OF LOS AN 13UI LDIP1! ND SAFETY .
Ceftified copy is filed with the county building iFOR APPLICANT"TO.F
inspection FOR IN BUILDING 9
departmentp - ,ADDRESS
Date ' Applicant (PRINT OR TYPE_ONLY) — L¢�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE / NEAREST }
(This section need not be completed if the' work involved ABSORPTION UNIT', BTU /�f 0� CROSS ST. a
,by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROC SED.Y I V
I certify that in the performance of the work-for which this AIR HANDLING UNIT,C`EM cc
permit is issued, I shall not employ any person in any manner L=/L �!
so as.to become subject to the Workers'-Compensation Laws. BOILER,BTU ~
r APPROVALS DATE INSPECTOR•SSIGN ,URE U'
Date Applicant COMPRESSOR,BTU_l� V/1SG p ROUGH N
NOTICE TO ftEPLICAT(T: If, after making this Certificate of VENTILATION SYSTEM FINAL - ���� Z
Exemption, you should become subject to the Workers' er
Compensation provisions of the Labor Code, you must-forth- EVAPORATIVE,dOOLER VALIDATION
with comply with such provisions or this'permit shall be ,
deemed revoked. FURNACE: - FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU,
I hereby affirm that I am licensed funder provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3'of the Busi- - 'WALL
ness and Professions Code,-and my license is in full force and
effect. qq��
License Numbc=_J h,P Lic'. Class�r�
Contractor Date
0 I am exempt from-the licensing requirements as I am'a ,
licensed architect 'or a registered professional engineer Plan.check fee 25%of above.
acting in my professional capacity (Section'7051,Bus-
iness and Professions Code). PERMIT ISSUING FEE'$
Lic,or Keg.No. Date TOTAL FEE
'HOME OWNER-BUILDER DECLARATION
PLAN CHECK APPLICANT ,
I hereby affirm that I'am exempt from the Contractor's, NAME _a AJ A-I'
'License Law for the following reason (Section 703'1.5, Busi-
ness and Professions Coda): ADDRESS0 $.
-1,•as owner of .the property, will do the work and the' y�� TEL. NO.
structure is not intended or offered for'sale (Section' Cl•T / �
7044, Business and Professions Code). —(/-
OWNER;
I, as owner of the property, am•exclusively contracting
with licensed .contractors to construct -the project - MAIL 'b 0,51A
(Section'7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL,.NO. #'o o e o [I J•,
I hereby affirm that there is a construction lending agency I,O�� —
,,for the performance of the work for which this permit is CONTRACTOF n/O
TO
issued(Sec. 3097,Civ.C.). ,�/ —'(r/fr" 2. 0 0 �J,7,
Lender's Name — ADDRESS '//�„�i017_ � ?o 0 0 317 00v-
Lender's AddressCITY ^�/u��tr�T,E_LL..NO.�• �`/ (gf&_ 5'Pl - -
I certify that I have read this application and state that the STATE LIC. � a O"I;-8O
above information is'correct.I agree to comply with all County LICENSE NO Z�-�Q - CLASSI���=, A401
ordinances and State laws regulating Heating,Ventilating and'
Air Conditioning, and heieby•authorize represen0fives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Ccnty to enter upon -the above-mentioned property for
i sl ection purFQses ;
di,nature of Permittee Data.