HomeMy Public PortalAbout9304 LA ROSA DR_Mechanical__ „WORiERS'COMPENSATION DECLARATION 76A364C-. pp rq
I hereby affirm that I have a' certificate of consent to self CE -818 (2-80) 6�1� �C A T Q®N FOR P E R� T
insure, a copya,certhereof-(Sec.
-(Workers'Compensation Insurance,of HEATING-VENTILATING-MIR CONDITIONING
a certified//'copy thereof�(Sec. 3800,Lab.C.) ' -
Policy N41-9601 Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANG ES- BUILDING AND SAFETY
�( Certified copy is filed with the county building inspection
departme 1 1 FOR APPLICANTqJ� /. TO FILL IN BUILDING 2 c4 z gasDa /�t��� 7' ApplicantC�lt �'C �rs'fA K ���'/i1�� (PRINT OR TYPE ONLY) ADDRESS gas
CERTIFICATE OF EXEMPTION FROM WORKERS' NO; TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION,UNIT, BTU CROSS ST.- /r
by the permit is O
for one hundred dollars (5100) or less.) 'DISTRICT N0: PR S cD BY 0
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 / O
so as to become subject to th/le'Workkers'Compensation Laws. BOILER, BTU H
Date/�•-n�o ?''Applicant L���7 ��1MA�E�O'r���Z ✓� APPROVALS DATE” iNsaEcroR'ssicr ,URE lU
COMPRESSOR,�BTU�7�j 08D �D . ROUGH' I j —y .60 �7 b� y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMZ
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Laboi• Code, you must forth= EVAPORATIVE COOLER
with comply with such provisions or,this permit shall be VALIDAT
deemed revoked. FURNACE: FAU RAVIT
LICENSED CONTRACTORS DECLARATION FLOOR BTU_ Q-0 Q �.
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
ness and Professions Code, and my license is in full force and
effect.
License Nu/mbe aF O�o• Lic.Class
Contracto(/N.y�. �/M n at -
❑ 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 professiorial capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ 00
Lic.or Reg.No. Date TOTAL FEE 27
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 703.1.5, Busi-
ness and Professions-Code.): . ADDRESS2 2 8 2 8 A
❑ 1, as owner of the property, will do the work and the I c NO
TEL. .- c•� 4:1
structure is not intended"or offered for sale •(Section CITY
7044,'Business and Professions Code).
OWNER 2 2700
❑ I, as owner'of the property, am exclusively'contracting / U/C
with licensed contractors to:.construct the project •MAIL 2
(Section 7044, Business and Professions Code). ADDRESS 7Qx
CONSTRUCTION LENDING AGENCY CITY �M /J��� ei TEL NO1Q2 2 8-8 Q
I hereby affirm that there is a construction lending agency 0
for the performance of the work for which this permit is CONTRACTOR��1� �L1�7L--�
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address
CITY . � �� TEL.-NO.
I certify that I have read this application and state that the STATE y / LIC. Q
above information is correct. I agree to comply with all County LICENSE'NO: CLASS
ordinances and.State laws regulating Heating, Ventilating and
Air Conditioning;and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon th'e above-mentioned property for
iuspection-purposes.N � / C7 ��_M�� C`� L/C #- ��/•
Signature of Permittee Date