HomeMy Public PortalAbout9931 LA ROSA DR_Mechanical__ WORKER'S
have a certificate
DECLARATION 76A36,1C W 9/59 APPLICATION FOR PERMIT .LIME GREEN
by.affirm that I have a certificate of consent to self insure, 76A364C
c ertificate of Worker's Compensation Insurance, or a certified- HEATING - VENTILATING-AIR CONDITIONING '
(thereof(Sec.3800 Lab.C.)
y No. CompanyCOUNTY 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 - BURR s8
department. /,/f p /'//j,r/f (PRINT OR TYPE ONLY)
7-`�/I f�<i!_T(�I t(/` LOCALITY
Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
,COMPENSATION INSURANCE r CROSS ST.
ABSORPTION UNIT,BTU
section need not be completed If the work Involved by the ASSESSOR
MAP BOOK C'l PAGES PARCE��
It is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM 'l✓
.1WRIcT NO. PROCESSED BY '
`fy that in the performance Of the work for which this permit -
�ed, I shall not employ any person in any manner so as to BOILER,BTU
1a subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPPOV s HATE INSPEGTOR'a SIGNATGRE'
Applicant VENTILATION SYSTEM
CE TO APPLICANT: If, after making this Certificate of - _ - ROUGH
Ilion,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
ions of the Labor Code, you must forthwith comply with such FINAL
Irons or this permit shall be deemed revoked. FURNACE: FAU GRAVITY "'� - VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU .+� -
by affirm that I am licensed under provisions of Chapter.9 SUSPENDED UNIT_
encing with Section 7000) of Division 3 of the Business and HEATER: WALL
sions Code, and my license is in full force and effect.
i Number �/ •tiL /✓ Lic.Class -
�or aCc e 1!/A //-/ 7--i/ ' ft a
f II am exempt under Sec. Plan check fel O
}I W
B.&P.C.for this reason PERMIT ISSUING FEE$ �"'. " •S �
LL
Date: TOTAL FEE f'A
r. . i 41) lil `,moi e
(Signature "- Q
- OWNER-BUILDER DECLARATION' PLAN CHECK APPLICANT
affirm that I am exempt from the Contractor's License Law NAME /'I ,.
Following reason (Section 7031.5, Business and Professions / �7-rl''r / - t`:��1A C'/ .�{ t.. {h'{I�+Jk a
W
I, as owner of the property, or my employees with wages - / �� �' �' - •• F
as (heir sole compensation,.will do the work and the CITY �)/ l��" TEL NO. -•-7 r"..��..-j (01101—c_U-yti I it -
:tructure is not intended or offered for sale (Section 7044, / f" < GAI I Ah
3usiness and Professions Code). OWNER
as owner of the property, am exclusively contracting MAIL JJ
lith licensed contractors to construct the project (Sec- ADDRESS
ion 7044, Business and Professions Code).
CITY �,�,.• STEL.NO.
CONSTRUCTION LENDING AGENCY FF /1!
,1 affirm That there is a construction lending a enby for / /
/ Y
rtormance of the,work for which this permit 9s issuetl CONTRACTOR / f�/.<,f�
f
_ ADDRESS � /f• � fl.,�.'. /R I'r/-f .•
I - CITY /.;./* // f L NO.
/der's Address ' STATE l./ u LIG ix -
tify that I have read this application and stale that the above LICENSE NO. c¢ 1,,,/. /'�i CLASS A .._
Talion is correct. I agree to comply with all County ordinances '
'tate laws relating to building construction,and hereby authorize ,
.natives of this County toZeon- the above-mentioned ,
t,y for inspection urpo SEE REVERSE FOR EXPLANATORY LANGUAGE
OFAPPLICANT AGE� HATE