HomeMy Public PortalAbout9564 LA ROSA DR_Mechanical__ WORKF�t'SCOMPENSATION DECLARATION 76A364C 46DPW 9/e9 APPLICATION FOR PERMIT LIME GREEN
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hereby aflkrrr AWat I have a certificate of consent to self Insure,
or a cert ificate"of Worker's Compensation Insu}ance, or a certified HEATING -VENTILATING-AIR CONDITIONING -
copy thereof(Seer 3800 Lab C)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy Is hereby,furnished
BUILDING
F-1Certified copy Is filed with the county budding Inspection FOR APPLICANT TO FILL IN ADDRESS G F Jle
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PRINT OR TYPE ONLY) 9S
department ( , r
Date Applicant LOCALITY 7.Pim-� Cc-�
pp NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �% 4 ,
COMPENSATION INSURANCE ABSORPTIO U IT,BTU CROSS ST / `�ra
ASSESSOR' pr '
(This section,need not be completed if the work involved by the MAP BOOK PAGE,.,,,-/' ,IIIPARCEL,02Z9f
permit is for one hundred dollars($100)or less). AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSE �
I,certify that in the performance of the work for which this permit "
Is Issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers' Compensation Laws -
COMPRESSOR,BTU /
' APPROVALS DATETORS SI(iNA
Date' Applicant VENTILATION SYSTE
NOTICE TO APPLICANT If, after making.this Certificate of ROUGH ,
Exemption,you should become_sublect to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY - VALIDATION
LICENSED CONTRACTORS DECLARATION I FLOOR BTU
hereby affirm that I am licensed under provisions of Chapter 9, SUSPENDED UNIT- "
(commencing with Section 7000) of,Division 3 of'the Business and / HEATER WALL 60
Professions Code,and my license Is In full force and effect J I !7
- 5 SCI .. Q 00
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Llcense`Number Llc Class gJ }
Contractor Date
U
a
El I check fee
I am exempt under Sec 0
B&P C for this reason PERMIT ISSUING FEE$ :Z'
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Date TOTAL FEE. d
Signature PLAN CHECK APPLICANT Z
OWNER-BUILDER DECLARATION
I hereby affirm that I am,exempt from the,Contractor's License La NAME Z
for the following reason (Section'7031 5, Busiriess and Professions ✓v 4A" J
Code) ADDRESS
❑ I, as,owner of the'property, or my employees with wag08
as their sole compensation, will do the work and th CITY r V TEL NO J/833/.• 3 /�J+/'• 8
structure is not Intended or offered for sale (Section 704 ACCTu8
Business and Professions Code OWNER d �/ 3303 1
,i 8.50
I, as owner 0-f the property, am exclusively contractor MAIL ITEMS
with licensed contractors to construct the project (Sec ADDRESS T A11 ITEt95
tion 7044, Business and Professions Code) CITY TEL NOS,, 3 '7 r 1 OTtrL 128 '-a0
CONSTRUCTION LENDING AGENCY R P / O„g-� r—( rtu��ctt�Lt� i
I hereby affirm that there is a construction lending agency for CONTRACTOR �'RG4ft 1?8,5[I
I performance,of the work for,which this permit is Issued
(Sec 3097,Civ C) ' I�LIe �E ,�I]
,ADDRESS” 4fffln -
Lender's Name
CITY' TEL NO n�n q
Lender's Address STATE LIC 4JilW-000 �i���Q�'
I certify that I have'read this application and state that the above LICENSE NO CLASS ES�JV� FPM91.4i ,
Information Is correct I ree to comply with all County ordinances
and Sia I ws relatingJto b riding construction,and hereby authorize
represent Ives of this Co my to entenupon the above-mentioned
prospe I n r ses SEE REVERSE FOR EXPLANATORY LANGUAGE
for In
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SIGNATURE rPPLIANT4 R AGENT DA