HomeMy Public PortalAbout10324 DAINES DR_Mechanical__ WORKERS'CgMPENSATION-LI CLARATI,ON ��--' -76A364C.- .n", �. AA ## qq� �g- N.
�®® (����//�� pp
�� CE=8' Y 12 80) �'I�,YC{''l. U -1,0 N. �®�.- 1� ��{�!t} 8T
I hereby affirm that I-have a' certificate-df conse,.t to.self., ' F,
insure or,a certificate of Workers'Compehsation=insurarice,or I, EATIR�G-VENTILATING-A1-R� CONDITION)N(a
Ga certid copy thereof(Sf�_�R�'Lab.( .1
Policy No., `7.�_C`oomp ny
Certified copy is hereby furnished. /.l✓Rn'ft�,'Lealai�, COUNTY'OF LOS ANGEL'ES4 {'BUIL'DING"AN D'SAFETY
0 Certified co is filed with the c8unt building
PY- Y g inspection • d ,��./
��,a y FOR APPLICANT,TO F,ILL;IN, '
Date`f" ,_ Applicant ✓!fes—rjr� ��� - � (PRINT'OR T.YPE,ON,L_Y) _ - ADDRESS _
LOCALITY ti
CERTI-EICATE'OF EXEMPTION FRO,M.WORKERS'' NO. . TYPE,OF APPLIANCE 09,,EQUIPMENT �� •--FEE:'
COMPENSf�TION INSURANCE s`
'N'E4REST
r
� CRO$S;ST:� d
_ r
(This',secfion.,need'not be completed if the'work involved ABSORPTION,UNIT, BTU ,p -
by';flte"perm t is for- one._hundred'dollars ($100) ,or less.) ": s t'-,�' b(STRitt,kd'', �"ZES�E,_
v �U=
I oertify,that in-the performance of the-work to which-this AIR HANDLING'UNLT,CFM
permit,is issued, I shall not.employ,any persdn in any manner,*`
`
'so As t&become s_ubject-tb the Workers' Compensation Laws. BOI'LE'R,vBTU�
/'� APPROVAL�uDAT INSPES�TO R'S SIGNATURE ILlU
Date '-Applicanf" = j COMPRESSOR;STU_ �0-" d
a` -, e / ,`�/ l�q.Ls' ROUGH: _ fn
NOTICE'TO APPLICANT.: If, after ,Iltaking°this'Cer'tificate-ctf VENTILATION SYSTEM .,>. r Z
'Exemption, you'should' become' subject to- the Workers' = FfNAC ti
n
Compensation provisions,of the La'bo'r-Code, you,must;forth= � ° ;-VAL1D;4TION` �, •
with' comply With 'such-provisions.or 'this_peint•shall�17e: EVAPORATIVE COOLIE -
deemed revoked:
FURNACE-:`" FAU -
LICENSED CQNTRACTORS DECLAR ATION ;: _ FLOOR:
BT] >-
-I hereby,affirm th"i I am.licensed under,provisions of Chapter HEATER:, ' SUSPENDED:, UNIT
9 (coni meriting with`Section 70001"',of Division•3'of,the Busi=- ;WALL
ness and Professions'Code, and my license is in full"force and r n �
effect.
License Numberc.=C[ass'•
Contractor Date -
. _ -s
I am'exempt from the licensing requirements as 'I am`a
licensed architect or a regisfeted"professional engifi ee Pian Check fee-25%Of abOVe.
acting in my -professional capacity (Section 7051,-Bus-
mess and Professions Code).. PERMIT ISSUING-FEE.`$
Lic.or Re No. Date- - -
g _ -TOTAL FEE
HOME'bWNER-BUILDER DECLARATION_, PLAN,CHECK APPLICANT
1.,,hereby-affirm, that I .am exempt from- the;Contractor's- NAME. -
f
License'Law'for the following reason ,(Section 7031.5;'Busi-'.
ness a_nd Professions Code): .. I- ADDRESS
24
J,•as,owner-of the property, will,do'the-worit'arid the.
• = sttuctiure,is notintended•,.or offered .for;sale (Section`
TY
7044, Business and Professions�odej.
O,WNER`. .
Iy.as owner of.the'property, am exclusively'contracting„
with,licensed' contractors So construct-; the -'project- � MAIL_' .' l `x` v
(Section 7044, Business arjd ProfessfoAs Code).. ADDF'ESS e - - - • - 3'
r ,.•' .. _ - °'• `�j CITY' NO; �ev
CONSTRUCTION LENDING AGENCY
I•hereby affirni that there is a construction lending agency
for°,the performance of:the work for which this permit is_
CON,TRAC.T.OR
issued(Sec."309,7,Civ.C.).
Lender's.Name ADDRESS
Oo> �� a `'� �• �_ ��
'Lender's,Address
„ C,ITYti?' .-• _ vTEL. W2,2
Q }'os
T certify that"I have read this application'and•state that-the
above,informationisc correct. STATE LIC:' �- t• ` �� t
3
o .,I agree to comply with all'G°dunty, LICENSE NO.•' �'.CLASSt
• ordinances and Sfate•laws regulating•Heating;Ventilating and �- ': • -'s ;,, .- -' ' . . '� � - '" ,' - •
.Air Conditioning,,and hereby authorize representatives of'tliisq,, o SEE REVERSE FO.R'EXPLANATORY.LANGUAGE` - -
County to enter. upon- theab,ve-mentioned°property for
`� -.� •� _ �`� • ter:o :, , . s -` ',� ..
• S�e of rermittee Date - � # •�� a � , � '�� _