HomeMy Public PortalAbout10214 DAINES DR_Mechanical__ „WORK *6'COMPENSATION DECLARAT10N 76A364C ' A @ ^ C N �/�
I h+rebv atYrtm that I have a certificate of consent to self CIE-818 (2 80) I(- tS.O`>,�t� B®�tl ®� UxTU ��
Insarl•'br a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATING-Al R CONDITIONING
a certified copy thereof(See 3800,Lab C)
Policy No. Company l
Certified copy is hereby furnished T O COUNTY OF LOS ANGELES BUILDING AND SAFETY
a l '
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN ADDRESS `V7{ - 15A/A/ AIJ .
DateApplicant (PRINT OR TYPE ONLY)
LOCALITY �y�'C�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -_ v`
F ”` '- COMPENSATION INSURANCENEAREST ,(
CROSS ST
�/�L�vva r1�
(This We
need not be completed_if the work involved ABSORPTION UNIT, BTU - - d
th
by e permit is for one hundred dollars,($100) or less.) DISTRICT NO, PROCESSED 8Y UO
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner �. cc
'so ag4o become subject to the Workers' Compensation Laws - BOILER, BTU 0
APPROVALS DATE INSPECT 'S SIGNATURE*
.V
'. Off—
Date1,-,!'VANf,'If,'after
p I i c a n t ff S" _,`� t COMPRESSOR, BTU-�? �'� a
/ , ' 1 ROUGH ,
NOTI, E TO APmaking this Certificate of ; VENTILATION SYSTEM FINAL NExemption, •yousould become subject to the.Workers'
Compensation provisions of the Labor Code, you must forth- }' EVAPORATIVE COOLER VALI ATION
with comply with sucK provisions or this permit shall be
deemed revoked. FURNACE FAU G AVITY j
LICENSED CONTRACTORS DECLARATION f FLOOR BTU_ �.;�-- /
I hereby aff"in that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
000
9 (commencing with Section 7000) of Division 3 of the,Busi- WALL
ness and Professions Code, and my license is in full force and
effect. S!`
License Number _�Z i Lic.Class. $
Contractor�t..��}Q��_�'�,�-•
I am exempt from the licensing requirements as I am a
licensed architect br a registered professional engineer Plan check fee 25% of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ p
Lie or Reg.No Date TOTAL FEES
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a
I hereby affirm'that I am exempt from the Contractor's NAME i' -1 D Qjt.,i-l —
License Law for the following-reason (Section 7031 5,•Busi- i (-T—tom' Y
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and thevL�N-►O- / �
CITY V�� 33 - ci.
-� � structure is not intended or offered for sale (Section '/��},}-D�� 4,(y• 1�_, E{•yL.fct
7044, Business and Professions Code). , jj 1e
On OWNER / r Cij? i iia
d, as owner of the property, am exclusively contracting _r2/��CX�C.
with licensedcontractors to construct the project MAIL Tij 4 4 �0
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY / /- w\ �*)i9-� L� f ��6 '
I hereby affirm that there is a construction lending agency /`} �L �I(�; +• r all!i
for,the performance of the work for which this',permit is CONTRACTOR
issued(Sec. 3097,Civ.C) y
Lender's Name ADDRESS���� ���� .� 4?.s•r�� ,l«I�tili���ll4i� 5/,,YEW
Address CITY p T_L-.NO
I certifythat I have red this application and state that the � )� - 2K.. i AN �01
a pp STATE LIC t�r.� P�
above information is correct I agree to comply with all County LICENSE NO. _ _��_ __ C ,ASip
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter _upon the above-mentioned properly for
inspectionur f se•- !
_
Signature of}�rmi..ee . Date