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HomeMy Public PortalAbout9558 LA ROSA DR_Mechanical__ WORKER'S k COMPENSATION Df consent to 7A3�CPW9/89 -APPLICATION FOR PERMIT LIME GREEN' I hereby?x�dn that bhave 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) \ 5 �_ Pohcy No J ���Company s��4L UWA �J ❑ , ' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. c Certified copy Is hereby furnished ICertified copy is filed with the county building Inspection FOR APPLICANT TO,FILL IN BUILDING •�a } 'department • (PRINT OR TYPE ONLY) ADDRESS 0 Y •'t APphcan LOCALITY x, NO TYPE OF APPLIANCE OR EQUIPMENT FEE _ ' 'CERTIFICATE OF EXEMPTION FROM'WORKERS" 3 NEAREST 'COMPENSATION INSURANCE CROSS ST V_ ABSORPTION UNIT,BTU �q (This section need not be completed If the,work Involved by the ASSESSOR r— O�A" ' MAP BOOK � `O• PAGE PARCEL�'� permit is for one hundred dollars($100)or less) , AIR HANDLING UNIT CFM , l'certify-that In the performance of the work for which this'permit 1 DISTRICT NO PROCESSED eV Is Issued, I'shall not employ any person In any manner so as to BOILER,BTU C become subject to the Workers' Compensafion Laws ' ' I I - - �_t�' Gr�ta< f�✓ 3' I COMPRESSOR,BTU APPROVALS' DATE INSPECTOR S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE'TO APPLICANT If, after making this Certificate of ;ROUGH ' Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER + provisions of the Labor Code, you must forthwith,comply with such FINAL provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY LIC_ENSED CONTRACTORS DECLARATION I FLOOR BTUI IVY �~ VALIDA41h I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER WALL Professions Code,and my license is In full force and effect' License Number -/ 1� \� \' Llc Class' Contractor 'A�nd�b1 t1\yV�lt�11�OQ►\p a 1 ' ,, r2ir_CT a ' O Plan check fee :303 110.3.!` ❑. Jam exempt under Sec B RP C for this reason PERMIT ISSUING FEE$ T � � =. O Date . f!_l�r��i .6_I .0 TOTAL FEE /D Signature " . I: 10 HE,--K �1L.ial d PLAN CHECK APPLICANT .r (n OWNER-BUILDER DECLARATION nttt�� ¢j C_} Z I hereby affirm that I am exempt from the Contractor's License Law NAME fltt for the following reason (Section 7031 5, Business and,Professions Code) r ADDRESS- F1 ii ❑ j, as owner of the property-, or my employees with wages eclo}-C,1301, illi, L '` as their sole compensation, will do the work and the CITY TEL NO 7 ,}fC�it tltt f�tt7 structure Is not intended or offered for sale (Section 7044, 1 ttt Business and Professions Code) OWNER V �� ❑ I, as owner of the property, am exclusively contracting { - _ MAIL ' C1 �5� �•o\�©� �Y with licensed contractors to construct the project (Sec- ADDRESS r tion 7044,•Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY 1sZ� \yL TEL NOI�,C�-�Cb�-' 2 n hereby affirm that there Is a construction'lending agency,for the performance of the work for which this permit Is'Issued CONTRACTOR, ' (Sec 3097, Civ C) a� v S T ` , °• fix. ADDRESS -_, a _. Lender's Name ,, `` \ (� ° CITY9WWWW^'.1� TEL NO ,L�_+�r•�J� Lender's Address I STATELIC f I certify that I have read this application and state that the above LICENSE NO CLASS 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 prorty for Inspection purpo SEE REVERSE FOR EXPLANATORY LANGUAGEC\ DAN A' - , SIGNATUI OF APPIONT ORVLEfrf DATE c - -