The URL can be used to link to this page

Home My Public Portal About9813 LA ROSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION `FOR PERMIT - I heieb`y affirm' that I have a certificate of consent to self insure, ot,a certificate-of Workers' Compensation Insurance, - '- HEATING VENTILATING - AIR CONDITIONING a yertif'�ien/d///c�y7op//y Iherreeof (Sec. 3800, Lab. C.) � 76A364C - OOJIb J� �p�1EoM i .+ihc C e4,s,BIyyB(REV. 10/Bl) .. ❑cy No omparn - P t COUNTY OF LOS ANGELES - - BUILDING AND SAFETY , ny Certified copy is hereby furnished. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN - BUILDING tion department. ADDRESS { IJ--Y6 le /L(�J�FJ PRINT OR TYPE ONLY) / Date Applicant LOCALITY. P/is NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. - (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT No, PROCESSED BY the permit is for one hundred dollars ($100)or less.) �i AIR HANDLING UNIT, CFM �1 0 certify that in the performance of the work for which this -�` D .permit is issued, I shall not employ any person in any manner - - so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE INSP OR'S SIGNATURE Date Applicant COMPRESSOR, BTU 41-4 000 M 6 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Cade, yo,must forth- EVAPORATIVE COOLER VALIDATICI with comply with such provisions or this permit shall be -deemed revoked. - FURNACE: FAU V GRAVITY '�r ,}) LICENSED CONTRACTORS DECLARATION. FLOOR BTU (/' U(/ I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,.and my license is in full forcee and effect. License Number y�'37�s Lic. Class(/,' - , V Contractor �QNN 0" Date /— f 0 Q ❑ I am exempt under Sec. 2384,3 A W Plan check fee # e e e a e 8 H B:BP.C. for this reason' _ PERMIT ISSUING FEE $ Z Date: .( e - 6(150 Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - a - 3 Q 5 0 5 I hereby affirm that I am exempt from the Contractor's License - , 0 1 1 5_8 6 Law for the following reason (Section 7031.5, Business and NAME - - Professions Code): ❑ I, as owner of the property, or myemployees with ADDRESS wages as their sole compensation, will do the work and 'CITY TEL NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). [• - OWNER (,t �/V(i(/JyL LaIAJJ/C ❑ I, as owner of the property, am exclusively contracting , with licensed contractors to construes the project (Sec- MAIL- tion 7044, Business and Professions Cade). ADDRESS // OO J G- '7 CONSTRUCTION LENDING AGENCY CITY TEL. NO. t 7S-d y I hereby affirm that there is a construction lending agency for L P L�f the performance of the work for which this permit is issued CONTRACTOR196 NO/7. Ale ' .1A/4= 1111111 (Sec. 3097, Ci, C.). Lender's Name L 1 ADDRESS `9' 3 A) C f N I •/ 'q - ' - _ _. .. /� - CITY pti. �e 1 , TEL NO. Lender's Address - STATE LIC. I certify that I have read this application and state that the LICENSE NO. o 3 735 CLASS ` 3 9, - - - - - - above 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 - - -- upo the bove-mentFan roperty for inspection purposes. - SEE REVERSE FOR.EXPLANATORY LANGUAGE Signature of Applicant or Agent Date TION WORKERS'Th i I'hav a certificate of corse APPLICATION PPLIC ATION EOR PERMIT I hereby affbvm that I�inve o certificate of consent to self - F1rr /'1 1r, R rLRIY, ,1 .insLi e;pr a certificate of Workers' Compensation Insurance, - 16A364C HEATING -- VENTILATING - AIR CONDITIONING or a certi{ie co4p:1th0_j�eyn9800, Lab: C.) - RR 6! CE-818(REV. 10/81)- Policy No S Company lf.ew�^ - . Certified copy is hereby furnished. COUNTY OF LOS ANGELES_- BUILDING AND SAFETY Certified copy is filed withthe c y building in - -- FOR APPLICANT TO FILL IN - BUILDING `t} tion department. (PRINT OR TYPE ONLY) ADDRESS L... • Dote I o'I�9 Applicant LOCALITY e NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OFEXEMPTION FROM WORKERS' NEAREST - - COMPENSATION INSURANCE CROSS ST. - DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved by ABSORPTION UNIT, BTU the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT,CFM 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 become subject to the Workers Compensation Laws, BOILER, BTU APPROVALS DATE INSPE R'S SIGNATURE Date Applicant 'COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' _ Compensationprovisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT16N with comply with such provisions or this permit shall be deemed'revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT_ '(commencing with Section 7000)of Division 3 of the Business HEATER: WALL 1 V and Professions Code,and my license is in full force and effect. - ' - — r Y Q d License Number -S5q D7�j Lic Class J3 - Poo. V { Contracta o. or QAt Date . ❑ I am exempt under Sec. W Plancheckfee w B.BP;C. for this reason' PERMIT ISSUING FEE $ Z Date: Signowre TOTAL FEE Q - OWNER-BUILDER DECLARATION PLAN,CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ► Law for the fallowing reason (Section 7031.5, Business and NAME - 3 1 t 6 A Professions Code): - ❑ I, as owner of the property, or my employees with ADDRESS # • • s • e.8 wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. - I e e 2 O 5.0 , 7044, Business and Professions Code). ❑ OwNE c�L l A I' _ I, as owner of the property, am exclusively contracting • ' f C Q 5�v with licensed contractors to construct the projec((Sec- WAIL 1 - - tion 7044, Business and Professions Code). ADDRESS CJJ I n 1 O_8 5 CONSTRUCTION LENDING AGENCY - CI L TEL NO.'�,�� Z V, I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACT r ��.r ► (Sec. 3097, Civ. C.). - .. ADDRESS Lender's Name - CITY TEL NO. 553 •. . Lender's Address STATE LIC. I.certify that I have read this application and state that the LICENSE NO. CLASS Al - - a"orrect correct. agr ee laws re t gze rep se t Ivntio ed rty for inspecti n pu oses. SEE REVERSE FOR.EXPLANATORY LANGUAGE T � �ig nature of A,p,c.nt or Agent