HomeMy Public PortalAbout10030 DAINES DR_Mechanical__ • , _ - /� p - - . fie - -
SYCx`KERa'COMP,L�NSNTION IaECLARATION '16CEP-'818 C(2-80) •�"�P P I ' 8C A T 0 O p tl FOR PERM' IT
I hereby affirm that I have a certificate of consent to self
insure,or acgrtificateof Workers'CotnpensationInsurance,or 'HEATING-VENT ll..ATUNG-AlR-CbNDITIONING- ,
' a certified copy;fhiprof(SL' -4900,•L6b.-C:) ;
Policy,"No,w , Company—�-i�.iw.o.7F; _
Certified copy is dereby,turnished `;COU111T.Y-OF LOS ANGELES,, :BUILDING.ANQSAFETY 2
Cert'fied copy is-filed with the county building inspection �` p - BUI DING�, r
deny tme r._ _ FOR APP LICi TY TO FI L,L,If�I L
�r /� ADDRESS
�t �� AP,pticanc_/ - - °(PRINT OR TYPE ONLY) •�.. � _.•i '�"�,;
LOCALITY' -
NO..' TYPE OF^APPLIANCE OR EQUIPMENT FEE,
_ v
CERTIFICATE O� EXEMPTION FROM WORKERS' _ rte._
F�-
COMiNSATION-INS>,.['RANCfi _, CROkAREST
SS ST J r
(This section-need-not be.completed if the work •involved -- ABSORPTION UNIT, BTU ��^,- _ a
by'the permit RS foi one hundred 'dollars (SI00) oI less.) ° DISTRICT NO s ESSE 8Y 0
I certify that in the performance of the uork`for'which`tliis �_. ,A1,R',111ANDLIING UNIT,CFM __ , e,
IPROC
-
-.permit•s,Issued, I shall not employ any person in hny manner
'5q $§'ta4beeoinesubjec't t6-the. Worker's' Compensation Laws `- BOILER, BTU
APPROVALS DATE ,1 SPE:TO S SIGNATURE ,
` Date AppllcanC COMPRESSOR,BTU ` ��'rtpC7�° ` �" - ROUGH Q
` �p �,.
NOTICE `I`O%AP'PLICXN4-:•I{,�$Pter making this- rtificate of- VENTILATION SYST,EM'6 FINAL / l 7 Z7 '
Exemptiizri, you s iould:beeorhe`subject to the Workers'" - G" _
C'onlpBnsat>on prgvisrgns of the Labor Code, you must forth- :�
EVAPORATIVE°COOLER VALIDATI.ON -
w�kh •comply With $veh pr4vlsions or this permit shall fie
deemed revolF@d FURNACE: -FAU -GRAVITY
LICENSED CONTRACTORSDEMARATION FLOOR . BTU
I hereby affirm that I dm licensed under provisions of Chhpter HEATER:- -SUSPENDED UNIT t
` 9 (cornameticiug with'Section 7000) of Division 3 of-the Busi. WALL v
news and Professions,Code,_and my license Is in full force and - a
license Number " / hic Class.}I _ �a Isf� 1�A:
aC+� o's'o-8
Contractor'-A Citi ST''w"t Date
I.am exempt from the licensing.requirements as,I am a -
ticensed• architect or a•registezbd 'professional engineer elan check fee 25%gf'abOve.
acting in'my profeSsionit capacity, (Section 7051, Bus- 4. V 9-,8 5
iness and Professions Code). PERMIT.ISSUING F.EE`$ U S� _
.Lic.,dr Reg.' _ Date' TOTAL FEE
_ ROME OWNER-BI)ILDER,DECLARATION PLAN•CHEtrK•APPLICANT'
' - v -• � _ •hn'c�'L(roti.S�r�t_��6—°�c LFsG• - - _- , _
I' hereby'affirm thu# I am'-exerpptftom the ,Contractor's-` NAME
.License Law for'the following reason (Section'7031•.5, Busi-
nessandProfessionsCode)- ADDRESS
I,. s'dwner of•the property_,'will do1be-%Vo&,' lid the CITY. `' TEL._Nb. � .'7=-7r'((� �
structure. is not,intended,qc offered for sale (Sections �,���� � - "
7044, business end Profgssions Code)" , '- P 'a k
.. bWNER ,
14, as owrier of the pco6erty, am excluslvely contractingl' I 1 a
with licensed contractors tb construct- 'the project', MAIL"
(Section 7044, BusiiiessandPcofeseionsCode): ADDRESS'
CONSTRUCTION LENDING AUENCY'- r CI FYI �� TEL.NOl �i -_L+, L {'
I hereby affirm that there is a constfgction lending agency'
for the p6r'forms,rce ,d -the work for which this permit is CONTRACTOR,
issued(See. 3097,Civ.C�• V `
LendersName ADDRESS �T,¢� :t,- (.J�� ST.
Lender's A2ldress r City l - 6A TEL NO:.-S I -
- �� l
I certify that_i have read°this application and.state that the, STATE / '1 I �� - LIC. '
above information is correct.I agree to comply with all County" - LICENSE NO`i =/ �`. CLASS +'3
grdinances and State'laws regulating':-!eating, Ventilating and -
^,Air Conditioning, and hereby authorize representatives-of this •-- SEE RVEVERSE-FOR EXPLANATORY-LANGUAGE= =
County 'to enter,,upon the above-mentioned properly, for -
inspection pugposes.
Signature of Permittee- Date