HomeMy Public PortalAbout4853 ARDEN DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
I hereby affirm that I have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMITLIME GREEN:
or a certificate of Worker's Compensation Insurance,, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No.796206 Company State Compensation COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.. LLL111
❑ Certified copy is hereby furnished.Insorance. Fund
® Certified copy is filed with the county building i s7 (PRINT FOR APPLICANT QTYPETQOLFILL IN BUILDING
UD �_ �,
department.
Date 2' 2-94 Applican / NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
NEAREST � —v
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. -
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not.be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) MAP BOOK PAGEQ ,> PARCE '
.AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
1 certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to. BOILER,BTU
become subject to the Workers'Compensation Laws. / D
/ COMPRESSOR,BTU � -
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM I
NOTICE TO APPLICANT: If, after making this•Certificate of ROUGH1�3/" g
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL _41 -
provisions or this permit shall be deemed revoked. FURNACE: FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU t./.- VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT "
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number 471984 Lic.Class C20
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ContractorDSI'J WEHANICAL- CORP- Date 2-2-94 ' p
❑
Plan check fee V
I am exempt under Sec.
CC
B.&P.C.for this reason PERMIT ISSUING FEE$ Zell ifp O
Date: TOTAL FEE
z- a
Signature - ..., .
PLAN CHECK APPLICANT U)
OWNER-BUILDER DECLARATIONf - ,a 7
I hereby affirm that I am exempt from the Contractor's License Law. NAME � � dl -��� , 7^
for the following reason (Section 7031.5, Business and Professions ^''-`='
Code):
ADDRESS � ���j�(� � G
,»..rrss 1�?,s'
A � of< p;`>
ElS.� I I, as owner of the property, or my employees with wages - "=
q �� �/�� s '1 {-� Ti-
as
their sole compensation,, will do the work and the CITY V'V/�1.�'0.]4�•1 -TEL.NO. 1 � �W,t
structure is not intended or offered for sale (Section 7044, L
Business and Professions Code). OWNER fy`,t , 'i f
_ 3
14
F-1
1, as owner of the property, am exclusively contracting MAIL ? ;•'i� -
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).'
CONSTRUCTION LENDING AGENCY CITY �,' q TEL.NO. j 5 t i
N1 .tj S t €F 3
hereby affirm that there is a construction lending agency for �f ^- '`s`•'
the performance of the work for which this permit Is issue CONTRACTOR DSG MECHANICAL CORPORATION ' _1 t-_z-s � r
s .• c-.
(Sec.3097,Civ.C.). -
ADDRESS 5747 McCully Street
Lender's Name
CITY Chino TEL.NO(") 591-2274
Lender's Address [ TATE LIC.
I certify that I have read this application and state that the above LIC NSE NO. 471984 CLASS C-20
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 ins pn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
DATE
SI ATURE OF A O N ,