HomeMy Public PortalAbout9922 LA ROSA DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-00410 9/89 APPLICATION FOR PERMIT LIME GREEN
I hgra Yin [marl have a certificate of consent to self insure, 78A364C
or certifigate of Wor':ef.a-Compensation Insurance, or a certified HEATING- VENTILATING -AIR CONDITIONING -
copy thereof(Sec.3800 Lab.C.)
Policy No., 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 'UDREss
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALI a_ �T;a-,Z)
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSSS .
ABSORPTION UNIT,BTUASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit 19 for one hundred dollars
($100)or less.) AIR HANDLING UNIT,CFM
OISMICT Na. PROCESSED By
I certify that in the performance of the work for which this permit
is issued, shall not employ any person in any manner so as to BOILER.BTU /)
become subject to the Workers'Compensation Laws. Cl
COMPRESSOR,BTU
Date Applicant VENTILATION SYSTEM aPPsovaLs Dare IrvsPscroessmNarua %
NOTICE TO APPLICANT: If, after a this Certificate of ROUGH '-
Exemption,you should became subject to orkers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAD —GRAVITY
LICENSED CONTRACTORS DECLARATION AJ. FLOOR BTU d"O VALIDATIONS
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and�effect.
License Number Sb k_yz> Lia ClassSr�Z�1.
IL
Contraclor_S�'V%p��d�nt'7snate� 4AI9 l 00
❑
am exempt under Sec. Plan check fee
cc
B.&P.C.for this reason PERMIT ISSUING FEE $ O
Date: TOTAL FEE ,sD w
V6ignature sm
WN UILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that m Bze t from the Contractor's License Law NAME ,
far the following reason n 7031.5, Business and Professions -
Code): ADDRESSs
❑ I, as owner of the property, or my employees with wages AC:'I °t
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, -._ 4 it°
Business and Professions Code). OWNER ;TENS
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS li'AL 47- 50
tion 7044, Business and Professions Code), ^FEECF: -.
CONSTRUCTION LENDING AGENCY CITU TEL.NO. t' != 't �}j°_li i
ME
I hereby affirm that there is a construction lending agency for - , H�t]J_
the performance of the work for which this permit 9s issued CONTRACTOR
(Sec.3097,Civ.G).
ADDRESS
Lender's Name
CITY TEL.NO. .J
Lender's Address STATE LIC.
I certify that 1 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 County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
!> �
SIGNATURE OF APPLICANT OR AGENT DATE ,�