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Home My Public Portal About9515 LA ROSA DR_Mechanical__ ION DECLARATI WOthat I have a certificate of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN ' 76A364C I hereby aftirm-that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy.is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADORES tt,� / PRINT OR TYPE ONLY) /J `^ �d�� department. ( ' LOCALITY: - Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE f i NEAREST J I CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. v v COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be.completed if the work involved by the MAP BOOK PAGE 19 11 PARCEL 00 permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED By I certify that in the performance of the ork for which this permit is issued, I shall not employ any per in any manner so as to BOILER,BTU become subject to the,Workers'Com sation Laws. :I ®® VO` •-� COMPRESSOR,BTU Date ° pplicant APPROVALS DATE INSPECTOR'S SIGNATURE VENTILATION SYSTEM NOTICE TO APPLICANT: If, after mak' g this Certificate of ROUGH Exemption, you should become,subject tot a Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY V LIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class d Contractor Date 0 ❑ I am exempt under Sec. Plan Check fee BAP.C.for this reason PERMIT ISSUING FEE$ 0 Date: TOTAL FEE U W Signature (- PLAN CHECK APPLICANT - CO OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions , s.•: t r.-. Code): ADDRESS -- ❑ I, as owner of the property, or my employees with wages 't'=' F„ as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERVyn 06;`7 „5 ,-J,°4a byF I, as owner of the property, am exclusively contracting MAIL es, with licensed contractors to construct the project (Sec- ADDRESS 1 � {��/do tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY �! } TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit Is issued (Sec. 3097,Civ. C.). $ } 1 ADDRESS Lender's Name 4tF fl„I CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS infor ation is correct. I agree to comply with all County ordinances , an tate laws relating to building construction,and hereby authorize re sentatives of this ounty to enter upon*the above-mentioned P, for inspe):ti poses. SEE REVERSE FOR EXPLANATORY LANGUAGE 1/C l l IGNATURE APPLICANT 0 AGENT DATE WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby ,tf;irm.that I have a certificate of consent to self insure, Or•a.certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 Policy No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS T. IV 3 ! 10 (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED e the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ y person' any manner 0 sous to become subject to the W ers' Com nsat,on Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date 1(LI�' ! /'APPlicant COMPRESSOR, BTU ROUGH r NOTICE TO APPLICANT: If, after m In this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU J I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT — (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. License Number Lic. Class Contractor Date ❑ O I am exempt under Sec. Plan check fee V W B.&P.C. for this reason. / �rJ H Date: PERMIT ISSUING FEE $ [� !J Z Signature TOTAL FEE J! OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS - wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. -.--,-q 7044, Business and Professions Code). _:1_I;' 5 OWNER t=' "I I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL S iso s� QTi-, Tion 7044, Business and Professions Code). ADDRESS /�' -i-1 =iE 5-1 ` 5 CONSTRUCTION LENDING AGENCY CITY„ /LTEL. NO. '�� `gy7 p '/ v f I hereby affirm that there is a construction lending agency for , aG.:i% the performance of the work for which this permit is issued CONTRACTOR - (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. - — `I"';•'ay Lender's Address STATE LIC. - A.;. 1 certify that I have read this application and state that the LICENSE NO. CLASS above int rmation is correct. I agree to comply with all County ordinan s and State laws relating to building construction, and h eby authorize represe tives of this County to enter upon eabove-mentioned r erty for inspection purposes. A SEE REVERSE FOR EXPLANATORY LANGUAGE r( � Signature of App' ant or Agent Date ©s