HomeMy Public PortalAbout9450 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
her affirm
APPLICATION FOR. PERMIT
that I have a certificate of consent to self insure, _ L MAE G RE EN
or a certificate df V6orker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING ,
copythereof(Sec.3800 Lab C)
Policy No Company COUNTY-OF LOS ANGELES DEPT OF PUBLIC-WORKS .-BUILDING AND SAFETY DIV.
e r ertihed copy is hereby furnished.
❑ Certified copy Is filed with the count building inspection ci FOR APPLICANT TO FILL IN BUILDING
Y 9 P ADDRESS
department. �- (PRINT OR TYPE ONLY)'
Date / Applicant *" LOCALITY
( / NO TYPE OF APPLIANCE OR EQUIPMENT FEE`.
CERTIFICATE,OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE
Mf'
ABSORPTION UNIT,BTU ASSESSOR •• •
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL ,
permit Is for one hundred dolWs($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY
I certify that in the.performance of-the work for which this permit' ;
Is issued, I shall•not employ any person in any manner so as'to BOILER BTU Z -
become subject to the Workers' Compensation Laws. D� 4 f
COMPRESSOR,BTU
Date Applicant APPROVALS' DATE IN OR'S SIGNATURE
PP VENTILATION SYSTEM _
NOTICE TO APPLICANT:'If, after making this Certificate of ROUGH
Exemption,you should-'become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the LaboCode,'you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUA GRAVITY'- VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR' BTU
IF
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with`Section 7000) of Division 3 of the Business and HEATER WALL
Professions Code;and'my license is in full force and effect.
License Number 5 .�e ACCT.�Lic Class
Number— t19'
37303 95 2-
5 ,0
Contractor ►��( �� �/�Or7tH �Y—" i ITEMS� `, U
Plan check fee' Y ! t t
❑-. I am exempt under Sec " I
}i}IFIL. _ 5m ' 0
e.&P.C.for this reason PERMIT ISSUING FEE $
F-
Date: .. TOTAL'FEE., Q/( {aE{' i�:`� 'r
Signature J a `_� W
t.H ;NGE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm.that I amiexempt from,the Contractor's License Law NAME.
for,the.following reason (Section 7031.5, Business and Professions ,f ;LIDO-I� � /E'ljl f'7-1
Code):
❑ I, as owner.of the property, or my employees with wages DRESS J` I I� 4 at� o+}
as their sole'compensation, well do the'work and the - CITY TEL NO 1
structure.is not intended or offered for sale (Section 7044, - -
Business and Professions Code). OWNER
❑, I,'as owner of the property, am'exclusively contracting MAIL
with licensed contractors to construct the project (Sec-. •- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION'L'ENDING AGENCY CITY TEL N
hereby affirm that there Is a construction lending agency for CONTRACTOR I
the performance of the-work for which this permit is issued Op -
(Sec. 3097, Civ C.)
ADDRESS'
Lender'_s'Name
CITY TEL
Lender's Address STATE LIC
_ I certify that I have read this application and state that the above LICENSE NO. CLAS a 4
Information Is correct. I agree to comply with all County ordinances '
and State laws relating to building construction,and hereby authorize
representatives of this County'to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE' '
SIGNATURE OF APPLICANT OR A DATE -