HomeMy Public PortalAbout10154 DAINES DR_Mechanical__ COMPENSATIONDECLARATION 20-0046 DPW969AP',PLICATION FOR PERMIT' `IME GREEN V� ER'S
76A364C
I hefty affirm that I have a certificate of consent to self Insure,
,or a certlflcate,of Worker's Compensation Insurance, or a certified' s
copy thereof(Sec 3P,00 Lab c) b HEATING;-VENTILATING-AIR CONDITIONING s ,
Policy No' ad Company 5e7ZE M COUNTY OF LOS ANGELES '- ,, 'DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.,
'Certified copy I 4eby furnished
Certlhed copy Is filed with the count buildingInspection 1IN' .` BUILDING
L��}J y FOR APPLICANT TO FILL(PRINT OR TYPE ONLY) ADDRESS, �
�V ',department
' s ��t LOCALITY
Date o Applicant ;JLC
NO `TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTI KNEARESTATE OF EXEMPTION FROM WORKERS' - CROSS ST
COMPENSATION INSURANCE
^E• ABSORPTION UNIT,-BTU ASSESSOR. T�-�
(This section need not be completed If the work Involved by the,r. MAP BOOK !sI�u" PAG�7 PARCEL
permit Is,for one hundred dollars($100)or less.) , AIR HANDLING UNIT,CFM -
DISTRICT NO _ h PROCESSED BY _
I certify that In.the performance of the work for which this permit 0.1
iS Issued;I shall not employ'any person In any manner-so as to BOILER,BTU-
"-become subject to the`Workers'Compensation Laws !Q
COMPRESSOR,BTU
_ APPROVALS DATE, - INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making`this Certificate of ROUGH 'z�`9� ;at�
Exemption;you•should become subject to,the Workers'Compensation, r'
EVAPORATIVE COOLER q/
provisions of the Labor Code, you must,forth�vlth comply with,sdch FINAL �/C
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY V
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
'I hereby.afflrm thatil-am licensed under proJislons of Chapter 9 , HEATER SUSPENDED UNIT r'
,(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my hcense'i In full force•and effect
License Number, 03, LI `y B' ., �U A/O � •! ~^ •,5 I _
c Class
Contractor'�r 7fTlf iW Date 0•
❑ I am exempt under Sec Plan Check fee V
Q
B 8P C for this reason - PERMIT ISSUING FEE$ 6 a 0
Date -•TOTAL FEE d W
Signature d.
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION; Z
I hereby affirm that I am exempt from the Contractor's'License Law NAME Poo.for the following reason (Section 7031 5, Business and Professions �' -
Code) ADDRES!1 l.,? ? r h
FTl,,as owner of the property, or rry employees with wages " ' AC 'T
as their sole compensation, will do the work and the CITY --,TEL NO _j��/ • �, L—lI _
structure Is not Intended or offered for sale (Section 7044,'
Business and Professions Code) OWNER, 1 ;'ITEMS`
❑ a, I, as owner of.the property, am exclusively contracting ;,•
with licensed contractors to construct the;project (Sec- ADDRESS TOTAL
25'- 00 y
tion 7044, Business and Professions Code) Li /'tECK -
�
• '.-�+•- '. ,I. i._i'e 1[�,
CONSTRUCTION LENDING AGENCY CITY TEL NO CH''^- - - L{�, ,,j_•E' -
hereby affirm that there Is a construction lending agency for CONTRACTOR _ Poo. y F-1�lIrIt3E ,{El(
the performance of the work for which this permit',is Issued ��j G GO,G �G i(/ �j�G
(Sec 3097,Civ C) -
7. ADDRESS(
�p.3. qq
Lender's Name �1tfR l /.;:ti 3'1
-_
TEL NO r ,
1-
Lender's Address STATE LIC Hl+Lt I"-t
I certify that I have read this application and state that the above LICENSE NO �yl,3e CLASS
Information Is correct I agree to comply with all County ordmances
and State laws relating to building construction,and hereby authorize
representatives of thls,County to enter upon the above-mentioned "
propeFty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ^
TURE�APP�ICANTDA ,