HomeMy Public PortalAbout5120 ROSEVALE DR_Mechanical__ WHrrm that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby arcm that I have a certificate of consent to self
InsGre or a certificate of Workers Compensation Insurance HEATING - VENTILATING • AIR CONDITIONING
or a certified copy thereof (Set 3800 Lab C ) 7CEA 6 9(REV 10/01)
Policy No Compony
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDINGS-
tion department (PRINT OR TYPE ONLY) ADDRE
ad
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This stolon nand not be completed H ABSORPTION UNIT BTU
Involved the work Iolved by olsTRlcr no wocEssco BY
the permit Is for one hundred dollars (1100)or lass) 0
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM 0
permit Is Issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensations Laws BOILER BTU AP VA15 DATE IN CTOR GNATURE
APPIIcaW���-� ." COMPRESSOR BTU 00! � 9 ROUGH
NOTICE TO APPLICANT If after moking this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDAT
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU VITY D�
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter51 HEATER SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license is in full force and effect y
D d
License Numb L¢ ClassC ZU , V
c Date ��—O / O
V
❑ I am exempt under sy
Plan check fee d
H
B 8P C for this reason
Date Z
PERMIT ISSUING FEE $
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Cade)
❑ I as owner of the property, or my employees with ADDRESS
wages as their sole compensation will clothe work and
the structure Is not intended or offered for sale(Section CITY TEL NO 1 e,e a a o o
7044 Business and Professions Code)
OWNER
ElI as owner of the property am exclusively contracting • • •4 a o o5
with hcensed contractors to construct the project (Sec MAIL c
tion 7044 Business and Professions Code) ADDRESS Q J 2 b 4 8 7CONSTRUCTION LENDING AGENCY CITY TEL NO
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRACTO
(Se< 3097 Cw C ) G _
ADDRESS
Lender s Name
CITY TEL 50
Lenders Address
LIC
I certify that I have read this application and state that the` LICENSE N CLASS
above Information is correct I agree to comply with all County
ordinances and State jaws relating to budding construction,
and hereby authorize representatives of this County to enter
upon a abo e m hone roperry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date r