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Home My Public Portal About9518 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 7EA 86 8 (2-80) Q P p� C Q T�O N FOR p E R� T I hereby affirm that I have a' certificate of consent to self f insure, or a certificate of Workers'Compensation Insurance,or HEATING-F1ENTILATI(r r.-AOR COIN® a certified copy thereof(Sec. 380 L�_) �Policy No. Company COUNTY OF LOS ANGELE�� 11�§ � ISU/ISI/®A�If�I 'ela�lFfE� Certified copy is hereby furnished. Certi ied copy is filed with the BUILDING county gilding inspection �l aP t t. ) FOR APPLICANT TO FILL IN Date _/Applicar " • (PRINT OR TYPE ONLY) ADDRESS LOCALITY CERTIFICATE OF EXEIv TION FROM WORK NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } CROSS ST ,, d (This section need not be completed if the work involved ABSORPTION UNIT, BTU p by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. / P r ,SE BY U 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 mannerU! o ✓� O so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S GNATURE W Date Applicant COMPRESSOR, BTU ROUGH y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the Workers' FINAL z.c.�•• Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be eC deemed'revoked. - � . � , FURNACE: FAU': V_1_ - -LICENSED - 11 LICENSED CONTRACTORS DECLARATION FLOOR: BTU_j_}l [rlJV 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 effec�l��i��d License Number Lic.Class Contractor-.1— Date J_kt/ 0 1 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). Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS F1I, as owner of the property, will do the work and the z 4 �'4 A CITY TEL structure is not intended or, offered for sale (Section . NO. 1.lo o o 7044, Business and Professions Code). - # 8. I, as owner of the property; y contracting OWNER ert p p y; am exclusive! 2 o'11-'2'3 5 0 with licensed contractors to construct the project MAIL �ny (Section 7044, Business and Professions Code). ADDRESS 0,_ __ _ o o0 2 3,5 0 c=i _ _ _ 5 ! 8 2 CONSTRUCTION LENDING AGENCY CITY TEL.NO. A!_ 1 hereby affirm that there is a construction lending agency { for the performance of the work for which this permit is CONTRACT R i� issued (Sec. 3097,Civ.C.). Lender's Name ADDRESS Lender's Address CITY TEL.NO. f I certify that I have read this application and state that the STATEO. �� LIC. j .�� above information is correct.I agree to comply with all County LICENSE NCLASS !t0 ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upo the above-mentioned pro ,rty for ' spe do uses. /0) S996ture of Permittee rate -WORKER'S'COMPEN8S TION DECLARATION 20-W46 DPW 9/89 APPLICATION FOR PERMIT :� . 76A364C LIME GREE N I hereby affirm that I have a certificate of consent to self Insure, - , ora certificate of Worker's Compensation Insurance;or.a certified HEATING-VENTILATING -AIR CONDITIONING copy thereof(Sec 3800 Lab. C.) , Policy No. Company ti.\�aCOUNTY OF LOS ANGELES- DEPT OF'PUBLIC WORKS - BUILDING AND'SAFETY DIV. Certified copy is 2hereby furnished. Certified copy Is filed with the'county building I action FOR APPLICANT TO FILL IN, BUILDING dap ment (PRINT OR TYPE ONLY) LOCALITY /Jw Date `� l Applicant : NO TYPE OF APPLIANCE OR EQUIPMENT FEE. NEARE' CERTIFICATE OF EXE TIO F WORKERS' q,• C OSS 3T C� COMPENSATION 4NSU ANCE ABSORPTION UNIT,BTU'' This section need not be completed If the woik Involved b the ASSESSOR ( P Y MAP BOOK. PAGE PARCEL permit.is for one hundred dollars($100)or less.) AIR HANDLING,UNIT,CFM DISTRICT NO PROCESSED BY certify that in the performance of the work for which this permit'' is issued, I shall not employ any"person in any manner so as toBOILER;BTU become subject to the Workers'Compensation Laws COMPRESSOR,BTU` APPROVALS— � DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT:-If, after making this-Certificate of ROUGH Exemption,you should become subJect•to the Workers'Compensation provisions of the Labor Code, you must forthwith comply with.such EVAPORATIVE COOLER t FINAL provisions or this permit shall be deemed-revoked," FURNACE: FAU GRAVITY VA ATION LICENSED CONTRACTORS DECLARATION FLOOR BTU I,hereby affirm that I am'licensed under.provisions of Chapter 9HEATER SUSPENDED UNIT (commencing with Section'7000) of.Division'3 of the Business and'., WALL Professions Code,and my-license is in full force and-effect. -/ { 7)/ %c Ot> �� /� ��cense Number ? J Lic Class Li Contracto Date T1 'ram exempt under Sec. Plan check fee _V M:- B&P C for this reason PERMIT ISSUING FEE:$ ,5 00 :O Date: TOTAL FEE Q O U W g a Si nature PLAN CHECK APPLICANT U) WNE UILDER ECLARATION �'• oZ Z hereby affirm that I a exempt from the.Contractor's License Law, NAME for the following reaso .(Se61ction.7031 5, Business and Professions Code): ADDRES GG / / t_•�• 'a s I, as owner of the property, or my employees with wages as their sole•coaipensatlon, will do'the work and the CITY TEL* ��/ '` structure Is not intended'or'offered for'sale (Section 7044, F i- Business and'Professlons�Code)t OWNER �ITEMS ❑ I, as owner,of the property, am•exclusively contracting MAIL 'I rtL "� O0 �Rr_► r ' - with licensed contractors to construct,the project (Sec- - ADDRESS%J!�: r , ` •` Li! tion 7044, Business,and Professions Code). - CONSTRUCTION LENDING AGENCY CITY . TEL NO: i- 9r`, hereby affirm that there•is•a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR u, (Sec.3097,Civ C ( ADDRES / i i/vj° 11000"0130 1 tir.1';S 1 Lender's Name t� M CITY TEL•NO 7'CYy ; `rr} ,Lender's Address STATE ' LIC r- '1 certify'that I have read this application and,state that the above LICENSE NO Q CLASS information is correct.•]•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 " grope y for'inspection purp ses. .SEE REVERSE FOR EXPLANATORY LANGUAGE NA OF APPLICA AGENT OFATE