HomeMy Public PortalAbout9921 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION DEC LAflATION 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A364C
or a dertificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING -AIR CONDITIONING
copy 1flareof(Sec. 3800 Lab. C.) - L)
PoliY
cy o. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
•+Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING / I,
department. p (PRINT OR TYPE ONLY) ADDRESS 99z
LOCALITY T
Date Applicant Gii• / ��
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G��• .G
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR �Jp
(This section need not be completed If the work involved by the MAP BOOK SO / PAGE4PB7 PARCEL
permit is for one hundred dollars($100)or leas.) AIR HANDLING UNIT,CFM
OISiPICT NO. PPCCESSEO fiY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU p
become subject to the Workers' Compensation Laws. a
�,p P COMPRESSOR,BTU
Date X20 91 A titan �/ APPROVAL$ DATE INVECTOas!eiNANRE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after king this C ficale of ROUGH z.
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such Z I FINAL
,provisions or this.permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU V ATION
I hereby affirm that I am licensed under provisions of Chapter 9 TERSUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEA : WALL
Professions Code,and my license is in full force and effect. ! -
License Number--'�Lic.Class
/ �-
Contract - 7�` ' 1 0
❑ Z Plan check fee 30
I am exempt under Sec. IZ
8.8P.C.for this reason PERMIT ISSUING FEE$ F_
Date: TOTAL FEE /Q d
Signature to
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _ Z
I hereby affirm that I am exempt from the Contractor's License Law NAME �L _ �LLE� f�
for the following reason (Section 7031.5, Business and Professions V
)' ADDRESS
C�
I, as owner of the property, or my employees with wages 1
/7 /'/ H:•�1 .a
as their sole compensation, will do the work and the CITU �/'/� LE L/f•T' TEL NO. 3'f _5137
structure is not intended or offered for sale (Section 7044, � c
rr
Business and Professions Code). OWNER n1 1 I C11::4-313 - 00 ii xs
❑ 1, as owner of the property, am exclusively contracting MAIL TO-1'r1L "F 1'! _ 0t-1
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). CHECK 4-6.CID
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for •IJU
the performance of the work for which this permit Is issued CONTRACTOR iLLE.4s
!'I (Sec. 3097,Civ. C.).
r
ADDRESS UJi _ _
Lender's Name lll—illi iI 5/?ily`,'?
' CITY TEL.NO.
t Lender's Address 71�t.1 1 HI Ft t 7:47
STATE LIC.
I certify that I have read this application and state 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 Count�o enter upon the above-mentioned
property for inspection pu s SEE REVERSE FOR EXPLANATORY LANGUAGE
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