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Home My Public Portal About9903 LA ROSA DR_Mechanical__ WORKERS'C1)%111 `A r10N DFCLARATION 76A364C I hereby affirm 'that I have ( certificate of consent to self CE-818 (2.80) APPLICATION FOIA PERMIT insure, or a certificate. of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a crrtifiad cop) [hereof I Sac 3500,Lab. C.) Policy No. 0,mrany Certified cope is hereby furnished. COUNTY OF LOS ANGELES BUILDIN r D FETV D� Certified sop) rs Fikd with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. ADDRESS Uatc Applh ant (PRINT OR TYPE ONLY) LOCALITY C}.R]IIIC ATP OF 1X1,\IP7111N FROM WOR KE RS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE V COMPENSATION tNSURANCL NEAREST /j '.p '` >_(TI LJ(e (This section nerd not be COmple'ted if the work involved ABSORPTION UNIT, BTU CROSS ST. a O by the permit is for one humircd dollars (5100) or less.) FOISTRICTNO. PROS SSEDP L) 1 eartify that in the performance of the work for which this AIR HANDLING UNIT,CFM (% fr permit Ls issued. I .h.7 not employ any person in any manner so as to hecome •ul,jcct to the Workers'Compensation Laws. BOILER,BTU ♦- APPROVALS DATE I INSPECTOWSSIGNATURE LU Date Appli.ant--- COMPRESSOR, BTU ROUGH _ N NOTICE 10 kOPLICANI It, aft-r making this Certificate of VENTILATION SYSTEM z Exemption, vuu should become subject to the Workers' FINAL Compensaii.•n prnvsrms of L:le Labor Code. you must forth- with Comply .with such provismns or this permit shall be EVAPORATIVECOOL�E`R VALIDATION deemed revoked. FURNACE: FAU_/_N- GRAVITY DFLOOR:- L1CFNSL' t 'j% RACTORS UL CI.AR ATION FLOOR: BTU I herehy affirm that I am licen,ed under provisions of Chapter HEATER: SUSPENDED UNIT n Icummencing with Section 7000) of Division 3 of the Busi- WALL nes, and F4ofe,ainn, ('ode. ;:nd m-, licenw is in full force and effect. License Numhrr_ __— Lic.Class Contractor _—_ Oate__ y 1 am exempt from the licensing requirements as 1 am a �'/ lion+.d arc hl[u t or .t roistered professional engineer Plan e .�a abovS.` acting in m) professional capacity (Section 7051, Bus- ine,s and Prolas,Ions Code). �,ERMIT ISSUING FEE $1 g O Lic.or Rep No._._ Date TOTAL FEE HOME O\VNLR.BUILDER DECLARATION PLAN CHECK APPLICANT --.?3 4 a 0 A 1 hereby sffirm that 1 am exempt from the Contractor's NAME #ro o ° 0 0 8 License Lave for [Ira following reason (Section 7031.5. Busi- - - = /��-(`- r ties,and Yrnfe.s:uas Cud.) Ar REBS 2 ° ° 3 8 5 0 Ell. ., owner of the uroperts', will do the work and the CITY A TEL. NG��_ �/ ° ° ° J F 50.rza structure n not intended m offered for sale (Section =N. �I.p' ��rljs 1 7044, Business and Professions Code). OWNER /.Y 04.02-82 -I 1, as owner of the property, am exclusively contracting "\ with licensed contractors In construct the project aAl (Section 704.1. Business and Professions Code). A. CONS]RUC-TIUN LI NDING AGENCY �TY TEL NO. i hereby affirm that th,ry Is a cun,truction lending agency CONTRACTOR for the perfm.nams of the work for which this permit i5 Issued Sec 30q 7.C tc.C). / !V Lender., nn - ADDRESS al / Lender's Address CITY WWW TEL.NO. 1 certify that 1 have read this application and state that the STATE LIC. above information i,correct. 1 agree to comply with all County LICENSE NO. CLASS ordinances and State Iaws regulating Heating. Ventilating and Air Cony' tinning, ins hereby m autltoriie representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE CounCty ..o/f,rt- e.n m the above . 'lone for hispe ount t®/urr e1J Signatuu. t Permittee Date '76 WORKERS'Cr1MPI NSATION DECLARATION CEA$1 C APPLICATION P P p T N (� R PERMIT M I hereby affirm that I have a certificate of consent to self CE 818 (2 80) /'Y Ir Ir �C P`i •1 1 tl If- Y`C Ir IG Y'C IVY Q� /') insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING ,ILMI a certified copy thereof(Sec.3000,Lab.C.) Policy No. 04725CompanBEAVER INSURANCE y ?OC Certified copy ie hereby furnished. COUNTY OF LOS ANGELES ' �� BUILDING AND SAFTY n \� 9963 / T F1fl X�(] Certified copy is tiled with the county building inspection If FOR APPLICANT TO FILL IN BUILDING .� department. ADDRESS Date_#P#?*L— Applicant_BARNES_HEATING_&_A/C (PRINT OR TYPE ONLY) 3/3/81LOCAUTVI CERTIFICATE OF EXP:h1P710N FROM WORKERS' NO. ,TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST >_ (This section need not be completed if the work Involved ABSORPTION UNIT, BTU CROSS ST. 'S O by the permit is for one hundred dollars (SIOO) or less.) DISTRICT NO. PROCESSEDf„) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM C, picc permit is issued. I shall not employ any person in any manner so as to t:con: sub cc[ to [hc Workc• ' m- asatio� IU Laws. BOILER, BTU _ ♦— LI /// 3 ton / APPROVALS OA' AA _ INSPECTOR'S SIe. TURE Date_ _ Applicant_ 1 COMPRESSOR,BTU-3.6.,.000 10 00 HOUGH N NOTICE TO APPLICANT: If, after making thi, Certificate of I VENTILATION SYSTEM —�� z Exemption, you should become subject t, the Workers' FINAL Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked FURNACE: FAU$QM. GRAVITY— LICENSED RAVITY / h LICENSED CONTRACTORS DECLARATION 1' FLOOR: BTU LO OO 4r 1 hereby affirm that 1 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 license is in full force and effect. License Number.25.75.73_ Lic.Class._C-20 contract,BARNES HTG & A/C 3/3/81 I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan cheek fee 25%Of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). i 7 00 Lie.or Reg. No._ Date TOTAL FEE 27100 HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT /A ' 1 hereby affirm (hat 1 am exempt from tate Contractor's NAME License Law for the following reason (Section 70315, Busi- ness and Professions Cod:): ADDRESS p�3 La Rosa I, as owner of the property, will do the work and the 7 t TEL. NO. CITY / structure is not intended or offered for sale (Section TEMPLE_CITY R 4 3 7.0 A 7044, Business and Professions Code). ` OWNER - o o,o - 41 El I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL I 2 ^ - 27.00 (Section 7044,Business and Professions Code). ADDRESS I , CONSTRUCTION LENDING AGENCY CITY TEL. NO. e o o 2 7 0 0 v I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR BARNES HTG_& A/C 03, 1 2-81 issued (Sec. 3097,Civ.C.). Lender's Name ADDRESS 712 North Loren Avenue Lender's Address CITY AZUSA TEL.NO. 337-6732 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. 257573 CLASS C-20 ordinances and State laws regulating Heating, Ventilating and AirC^^•I lrioning, unit hereby v' orize representatives of [his SEE REVERSE FOR EXPLANATORY LANGUAGE _ 0 'y , enter ,aon the v --mentioned. proper' for ius^Ceti t -ignature i t �arm itte4 T llat/ /