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HomeMy Public PortalAbout10252 DAINES DR_Mechanical__ WORD<ERS'COMPENSATION DECLARATION CEA g g(2-80)' P IP L BC A T I®1 tl F R I� R 1�0 �T I hereby- affirm that I-have a certificate of consent to self insure, or a.certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a cer!ified copy thereof(Sec. 3800,Lab C.) PolicyCompany i COUNTY OF LOS ANGELES BUILDING AND SAFETY ` Certified copy is hereby furnished. - - - - , Certified copy is filed with the county building inspection BUILDING department. FOR APPLICANT TO FILL IN ADDRESS Date - Applicant (PRINTQR TYPE,ONLY) LOCALITY ��' 9/•7$x, i CERTIFICATt OF EXEMPTION FROM WORKERS' NO. -TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST, j COMPT NSATION INSURANCE (This section need not be completed'if the work involved ABSORPTION UNIT, BTU CROSS ST L.lYE �.,G�3t.OG/1l,(/ a0 by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCES BY U- 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 O S6 as to become subject to the Workers'•Comperisation Laws I BOILER, BTU ~ APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR, BTU !` ROUGH 0- 'NOTICE TO APPLICANT•: If, after making this Certificate of VENTILATION SYSTEM 2 Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION T with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY r LICENSEp CONTRACTORS DECLARATION' FLOOR,- BTU r I hereby affirm that I am licensed under provisions of Chapter HEATER- SUSPE � NIT �} 9 (commencing with Section 7000)of Division 3 of the•Busi- a WALL Nf A C/ • r/ ness and Profession's Cqde, and my license is in full.force and „ effect. License Number Lic.^Class Contractor Date I am exempt from then licensing requirements as I-arrt a� licensed architect or-a registered professional-engineer Plari check fee'25%of above. acting in'my professional capacity-(Section 7051, Bus- pERMIT-ISSUING FEE $ iness and Professions Code): Lic."or Reg No. Date - TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I•„hereby .affirm that 1' am exempt from- the Contractor's NAME L cense Law for the following reason (Section 7031 5, Busi-- 7 , s and Professions Cods):% - ADDRESS_ I, as owner of fhe property, will do the work and theTEL NO structure,is not -intended-or;offered for sale.(Section CITY q ". 7044, Business andTrot�essions Code) ' OWNER D $ 'I, as owner of,ahe property, am.exclusfvely contracting � with,licensed•contractors �to'c-otisfruct1 the project. MAIL ,yyam��,,, �� 2 5 9 3 A (Section 7044, Business and Professions Code) ADDRESS IDaSa _..•>I^/�S �� CONSTRUCTION LENDING AGENCY CITY / TEL:NO. Cl #:o o+o`o (� , I hereby affirm that there is a construction lending agency }I o•0 27,0 0 for the performance of the work for which this permit is CONTRACTOR ©(�(Jq�F�J _ issued (Sec. 3097,Civ.C.) -�- o,e o 2 70 0 6 � - Lender's Name ADDRESS :Lender's Address CITY TEL. NO. Q it 4­80 I certify that I have read this application and state that theSTATE LIC-- above information is'correct.I agree to comply with all County LICENSE NO. CLASS , lordinaiices 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 r.property for ins -•tion pprposes 4 [IJ\ A C)I Signature of Permittee Date' ` WORKERS' COMPENSATION DECLARATION, � I hereby affirm that I have a cert-iflcate of consent to self APPLICATION{ FOR PERMIT Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or ,6rtrhed copy thereof (Sec 3800, Lab C ) •76A364C 20-0046 DPW 9/88 policy Nb Company ' •Certified copy, is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY i ❑ `Certified copy is filed with the county building inspec-�, FOR APPLICANT TO FILL IN BUILDING ,)fir h tN'rS - tion department .� 'I ADDRESS (PRINT OR TYPE-ONLY) Date Applicant ` ., �,-- ^L .` a LOCALITY NO TYPE OF:APPLIANCE OR'EQUIPMENT S. FEE _ CERTIFICATE OF EXEMPTION FROM WORKERS' I NEARESST COMPENSATION,INSU RANCE ti -' '`�� j • -, SY,' CROSS This section need riot be completed if the work involved b ABSORPTION UNIT, BTU'- J - DISTRICT NO PR SED BY the permit is for one hundred dollars ($100) or less.) Y /0 K � ' certify that in'the performance of the work'.for which this AIR HANDLING UNIT, CFM' v i •permt""ssued, I siiall'riot,employ any person,m,any manner BOILER, BTU • soas to.become subject to the Worker '.Compensation Laws ,t tn T APPROVALS DATE INSPECTOR'S SIGNATURE Date 1'_ Gl � pplicant 3 COMPRESSOR, BTU �+ O d d �J' ROUGHYT Bs NOTICE TO.APPLICANT If, after making t is Certificate of VENTILATION SYSTEM FINAL Exemption,-you should- become' subject,to the Workers' Compensation provisions of-the Labor Code,'you'must forth- EVAPORATIVE COOLER VALIDATION with comply with,such provisions or this permit shall be deem- ed revoked • . . .• - •. t.• FURNACE FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU O '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 myJicense)s in ful).force and effectO U .T n� O` ?' License Number Lic,Class a. 0 Cont?actor Date' 'O I am.exempt under Sec F I.- Plan check fee W B&P C for this.reason d PERMIT ISSUING FEE $" H Date Z TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT , I hereby affirm that I am exempt from therControctor's License Law for the following reason (Section'7031 5, Business and, NAME Professions Code) . ` ' ADDRESS F-1- cas-owner'of•the property, or,mY'em to ees with' c lr+,�+T°Ys . wages as their sole compensation,well do the work and CITY TEL NO �41 _ the structure is not intended or offered for sale(Section L .35077°7c 7044, Business and Professions Code) OWNER" I, as owner of the property,-am exclusively contracting - ' 1, ITEMS With Iice nsed•'contractors to construct the project (Sec- MAIL• tion 7044, Busiriess and Professions Code) ADDRESS TOTAL 42.75 CONSTRUCTION LENDING AGENCY CITY TEL NO CIECK 2 Thereby affirm that there Is a construction lending agency for , t e the`performonce of'the work for"which this permit is Issued ' CONTRACTOR CHANGE °IND (Sec ,3097, Civ C ) ' ADDRESS . Lender's Name _ y CITY TEL NO 4�{IC�I-00O1 9/21/3-9 ° Lender's Address I certrf' that•I have read this a lication and state that the STATE LIC 3-821 1 8:1° Y PP LICENSE NO •CLASS above information Is correct,I agree to comply with alliCounty ordinances and State laws relating to building construction, and hereby`authonze representatives of this County to enter 'upon th above=m' boned roperty for inspection purposes i 5f / '2,•3-7/ �� SEE REVERSE FOR EXPLANATORY LANGUAGE SI ature of Applicant or Agent Date ©s