HomeMy Public PortalAbout9612 LA ROSA DR_Mechanical__ " y WORKER'S COMPENSATION DECLARATION 20.0046 DPW9/89
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I hereb Emir, that I have a certificate of consent to sell insure ]6A36°C' - APPLICATION FOR PERMIT'' LAME GREEN
or a deitihcate of�uJo'rker sCom Compensation Insurance or a certified ' HEATING- VENTILATING-AIR CONDITIONING I'
copy Var$of(SeC;3800 Lab.C J �.I
P❑oLIIcyINo'��Company COUNTY OF ANGELES' DEPT OF PUBLIC WORKS - BUILDING AND SAFETY'DIV '
Certified copy is•hereby furnished
❑ Certified cep y is filed with the county buillding:inspection FOR APPLICANT TO FILL'IN BUDRESSLDNG' C( -
+ department. ( ) ADDRESS "t�,
PRINT OR TYPE ONLY � "T 7—
y Date Applicant - 1 LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
;CERTIFICATE OF EXEMPTION FROM WORKERS, -
\ _ �._ �u
COMPENSATION'INSURANCE - - - ASSESSOR
_
` ABSORPTION UNIT, - T
(This sectmn rieetl•not be completed if the work involved,by the - .. - MAP BOOK PAGE" ' PARCEL" r • "•
permit is for onehdntlreA dollar's($100)or less.), AIR HANDLING UNIT,CFM -
!. DISTRICT NO. PROLESSEe BY^ q
I certify'ihat in the performance,of the work torwhich this permit - - "t
'is issued, I shall not employ any person in any manner so as•to BOILER,BTU p °
become subject to the Workers'Compensation Laws. r' _ - �i9a.' r
COMPRESSOR,BTU.- ,..
. .. • ..
APPROVALe' "DATE INSPECTOaSSIGNATURE
Date - Applicant VENTILATION SYSTEM. •-
I,NOTICE:40 APPLICANT: 1t, after making this Certificate,of _ - ROUGH °
+ Exemption,yo UIshould become subject totthe.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 - GRAVIT,Y -
LICENSED CONTRACTORS DECLARATION _ FLOOR BTU VALIDATION' "v
.hereby affirm that,t am licensed under provisions of Chapter 9 , S NDED 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. c.
license Number, Lic Class -
Contractor Date - 1 V
❑ ' I am exempt under Sec. - Plan check fee - IF
a - B BP.0 for IT -PERMIT PERMIT ISSUING FEE $ 3• wp _ _ O
Date: TOTALFEE:
5: off` W
z ^'Signature - r
PLAN CHECK APPLICANT N
�• ',•OWNER-BULDER'DECLARATION -' - _- - Z
l hereby affirm-that I am exempt from the Contractors License Law - Poo.
NAME_
or the following reason (Section,7031.5, Business.antl Professions
ADDRESS (`ir l_I % .F
_ I, as ownW'o`t the•property, or-my employees with wages - w
as then sole compensation, will do'the work and the CITY TEL.NO. - - _ tl�
structure,is not intended or offered for sale (Section 7044, -
T
Business and Professions Code). ' ' + OWNER _ 'i., � !. 1 t tai_• 'f,y. '
_, I, as owner of.the property'„am exclusively contracting MAIL - - -�; - ) - - -�� t...,
v'r.)with licensed contractors to construct the project (Sec- - ADDRESS ;t. it (•mL E
- ' tion 7044, Business and Professions Code). {I"it ✓ �^ t ” I-1' •
a
CONSTRUCTION LENDING AGENCY CITY TEL:NO. - CHANGE
I hereby affirm'that there is a construction lending agency for - - -i i
the performance of the work for which this permit is issued CONTRACTOR Hy
(Sec. 3097;Civ:C.). _ _ ;...N: rT r4T - ,
• ADDRESS
Lender's Name- 6 1/?-'
- ClTY+ ._ . TEL.N_0.. --... .- +�c� s5. e' F#1'1 y -Ji•I
Lender's'Address STATE= LIC— -_ -..... _ .. F �,,_ �.
I certify that I have read this application and at to 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 - r - t� •t'
property or inspection purposes. • SEE REVERSE FOR EXPLANATORY LANGUAGE - I •-
,
SIGNATURE OF APPLICANTO ENT �p- t