HomeMy Public PortalAbout9842 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
FOR
I�IC�OLI ��.
I hereby,,affirm that 1 have a certificate of consent to self CE -818 (2-80) A 1— Ir L� A J t V r R PERMIT
M
insure, ora certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
ocertified COPY thereof(Sec. 3800, Lab. C.)
PolicyCompany COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. -
Certified copy is filed with the county building inspection FOR ABUILDING
APPLICANT TO FILL IN
department. - _ ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
' LOCALITY'/'•
CERTIFICATE OP EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT 'FEE
COMPENSATION INSURANCE - NEAREST C����� �
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 1
.by the permit is for one hundred dollars (SI00) or less.) DISTRICT NO. PROCESSE+`By O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /)O cl
permit is issued..) shall not employ any person in any manner I
so as to become subject to the N'or' srs' I.,• pr anon Laws. BOILER, BTU O
-7 APPROVALS DATE irvSPECTOR'S SIGNATURE U'
LU
Dat</_z5=CO Ap plicap��.,. _ _ _ _ COMPRESSOR-,BTU ROUGH ��i �Q �-• d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM o i N
Exemption, you should become subject to the Workers' FINAL• + I—�7,r p� Z
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 CONTRACTORS DECLARATION FLOOR: ,BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED- UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WAIL -0 '
ness and Professions Code, and my'license is in full force andXcheck
�L .o�'s a a
effect. '���p(/1�,'� /�Q /J __� / _ C
License slumbef V-Y_� nor- LJ�ia Class`•_CJ7/ r��/
Contracto•�'.•A,, F�//[)ate_7`ZS_-"p�
ElI am exempt froluthe ,ensing requirements as I am'a
licensed architect or a registered professional engineer 5%of above. '
acting in my professional capacity (Section 7051, Bus �t
mess and Professions Code). PERMIT ISSUING FEE $ /
Lie.or Reg.No. " _ Date TOTAL FEE 0?2L_
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,
I hereby affirm that 1 am exempt from the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi- - 2 ] AA-7 A
ness.and Professions Code): ADDRESS _
I. as owner of the property, will do the work and the
structure is not intended or offered for Sale (Section CITY TEL. NO.
7044, Business and Professions Code). OWNER ^ 2.7,00
I, as owner of the property, am exclusively contracting ,• • • 2;7.0 0
with licensed Contractors to construct the project MAIL I
(Section 7044. Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY
CITY • TEL. NO. .. ���2 S"®'O;
I hereby affirm that there is ak for
lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sec.3097.Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO. .
1 certify that 1 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
Conn to enter upon the .• av nentioned property for
ins//..f-,li�n�tPu�rp�oses.upon, d t(�
Signature of Permittee Date