HomeMy Public PortalAbout10206 DAINES DR_Mechanical__ 'r YORKERS' COMPENSATION DECLARATIONI'MreAPPLICATION FOR PERMIT
'•,*sore bor afcertif cot�,of Worke srtCompensationie of elnsurannt to Celf
foga certified copy thereof (Sec 3800; Lab C ) CE-81c HEATING - VENTILATING - -AIR CONDITIONING
CE-818(REV 10/81) •
P❑olicyrNo Company
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 BUILDING
ADDRESS
tion department (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollars($100)or less.) 51 j��(
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 BOILER, BTU
so as to become subject to the Workers'Compensation Laws APPROVALS DATE ws R'S SIGNATU
DateZ Applicant ► COMPRESSOR, BTU ROUGH
NOTICE TO AP LICANT• If, after making this Certificate, o VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 WALL
and Professions Code,and my license Is in full force and effect
d
License Number d 5?' --Lc Class C3 , V
Contractor S "/ 1S�Dat� Z O
H
❑ j am exemjit under Sec d
Plan check fee
B &P C for this reason H
PERMIT ISSUING FEE $ .2 8 8 3.2 A Z
Date
Signature
TOTAL FEE ,a o Q
_
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ► • v o 2 05.05
Low for the following reason (Section 7031 5, Business and NAME
Professions Code)
El 1, as owner of the property, or my employees with ADDRESS 1'2 5 8
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO
7044, Business and Professions Code) '
OWNER / C
❑ I, as owner of the property, am exclusively contracting '
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business'and Professions-Code) ADDRESS —v.
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm That there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR'
(Sec 3097, Civ C ) ;
ADDRESS
Lender's Name G '
CITY 7, �r TEL NO
Lender's Address -
STATE v/ LIC
I certify that I have read this application and state that the LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State jaws relating to building 'construction,
and here authorize representatives of this County to enter
upon a bove-menti ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -