HomeMy Public PortalAbout9713 LA ROSA DR_Mechanical__ - W'ORI;ERS'COMPENSATION DECLARATION 76A364C APPLICATION
p �IOpI COp PERMIT
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I Fereby affirm that I have a certificate of consent to self
CE-818(2-80) Ar A 1tl f R IrERM
insure, or a certificate of workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab. C.) fl
7
Policy No. Company
COUNTY OFLOS ANGELES. Ti �� BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING 2 �/y�J.��/ n
department. ADDRESS 913 LFIQoriA
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE : CITY
COMPENSATION INSURANCE NEAREST >-
(This section need not be completed if the work involved ABSORPTION UNIT, BTU— CROSS ST. cc �r�l£'S O
by the permit is for One hundred dollars (SIOO) Or less.) DISTRICTNO. '/ PROCESSED 0
I certify that in the performance of the work for which this / AIR HANDLING UNIT,CFM r' (/ O
permit it issued, 1 shall not employ any person in any manner / `� } A
so as to become subject to the Workers' Compensation Laws. BOILER, BTU-/- -L.' v� F-
APPROVAtS DATE INSPECTOR•s SIGrvnTunE ii
I
Date Applicant COMPRESSOR, BTU ROUGH Cl-
NOTICE
NOTICE TO APPLICANT: If, after making.this Certificate of VENTILATION SYSTEM – - Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth-
with comply with Such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
FURNACE: FAU— GRAVITY—
LICENSED CONTR.4CTORSDECLARATION FLOOR: BTU '
1 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 licenseis in full force and
effect.
License Number Lie.Class
Contractor Date
I am exempt from the licensing requirements as i am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting inmy professional capacity (Section 7051. Bus-
iness and Professions Coda). PERMIT ISSUING FEE $
C.or RegsNo. Date TOTAL FEE 3 So
HOMEOWNER BUILDER DECLARATION PLAN CHECK APPLICANT
1 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
1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section 3 S 6'A
7044, Business and Prufessi(,ns Code).
{ 1 S> •e e'e • e
i, as owner of the property, am exclusively contracting OWNER 8�l ,
with licensed contractors to construct theroject MAIL
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(Section 7044, Business and Professions Code). ADDRESS L 0&8 21•;• 3350
CITY TEL.NO. ,pJ / S (f
CONSTRUCTION LENDING AGENCY _ 1��MLF' C�Y1Y -0.57) �� e oro 33.506
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sea 3097,Civ.C.). O 3.0'4.-8 2
Lender's Name ADDRESS
Lender's Address CITY TEL. NO.
1 certify that i have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Couo• •n enter upon the above^-^rioned property fur
i• .pectioa +� •—
XSignature of Permittee' Vale