HomeMy Public PortalAbout9571 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION DECLARATION z0o046DPW 9/e9 APPLICATION FOR PERMIT L� E GREEN
76A364C
I hereby affirm 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
I thereof(Sec 3800 Lab C)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certrfied copy Is hereby furnished
Certified copy Is filed with the county uilding Inspect) ` FOR APPLICANT TO FILL'IN ADDRESS ��-
department r (PRINT OR TYPE ONLY)
Date _31Applicant LOCALITY A '
V NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFI ATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST r'
ABSORPTION UNIT,BTU
This section need not be completed b leted if the work involved ASSESSOR
- ( P Y the � '� MAP BOOK PAGE PARCEL"' '
-permit Is for one hundred dollars($100)or less c 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
become subject to,the Workers' Compensation Laws
{ COMPRESSOR,BTU f2
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 FURNACEFAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
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 and WALL
Professions Code,and my license is In full force and effect
I L�
License Number Llc Class }
/� ,r-� -, 4 ' U
Contractor )t7- �(� ) f Date 3 =1-}`I u' m =;
p Plan check fee t_ �_E' ' ;- -_� 0
I am exempt under Sec -i o
B&P C'for this reason PERMIT ISSUING FEE Q HH�'6E e`-i� U
Date TOTAL FEE ' WW
Signature1' - t
_• t PLAN CHECK APPLICANT (�'li- Z�'•+-C`
OWNER-BUILDER DECLARATION ,y _
I hereby affirm that I am exempt from the Contractor's License Law NAME / ' 'I 42 C, 1 Ar!I G' -
for,the following reason (Section'7031 5, Business and Professions
Code) , " ,1' ADDRESS
I, as owner of the property, or my employees with wages ! fir/
as their sole compensation,pesation, will do the work and the CITY ,O� TEL NO
structure Is not intended or offered for_sale (Section 7044, C
Business and Professions Code) OWNER
❑ I, as owner of the'property,'am exclusively contracting MAIL �C
-,with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code) �-
CONSTRUCTION LENDING AGENCY- CfTY r ,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 /y� j J
(Sec 3097, Civ C)
ADDRESS �l ,
Lender's Name
CITY - TEL NO $__747'OS-4L,!
Lender's dress STATE Q LIC •e
I certify;hat I have read this application and state that the above LICENSE NO S� 7 { Q CLASS
mformatl n Is correct I agree to comply with all County ordinances
and Site
laws relating to building construction,and hereby authorize
repress tatives of.this County to enter upon the above-mentioned
props y for Inspegtio urposes_ SEE REVERSE FOR EXPLANATORY LANGUAGE
3 2 s
SIGNATURE OF APPLICANT OR AGE ,