HomeMy Public PortalAbout10414 DAINES DR_Mechanical__ ION
DECLARATI
b , WO,RKER'SCg7MPENSATate of consent to 76A3r6DPW9t89 APPLICATION FOR PERMIT LIME ,GREEN
76A364C -
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING ,
'copy thereof(Sec 3800 Lab C)
Policy No Company COUNTY OF LOS ANGELES ' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy IS hereby furnished t ^ 1
❑ Certified copy Is filed with the county building Inspection FOR APPLICANT'TO FILL IN ao�aess `�"� \ 1 C',k
department (PRINT OR TYPE ONLY)
Date Applicant' NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY eWl 'C` 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
' COMPENSATION INSURANCE" CROSS ST 4 _
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL s
permit Is for one hundred dollars($100)or less) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY
I certify that In the performance of the work for which this permit
is Issued, I shall not employ any person in,any manner so as to BOILER,BTU
'become subject-to the Workers'Compensation Laws !v/
COMPRESSOR,BTU 3
Date Applicant = APPROVALS DATE INSPECTOR S SIGNATURE
' PP VENTILATION SYSTEM
'NOTICE TO APPLICANT If, after making,thls Certificate of ROUGH '
Exemption, you should become subject to'the,Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE - FAU GRAVITY VALIDA ION
LICENSED CONTRACTORS DECLARATION FLOOR - BTU `
-1 hereby affiFm that Cam licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section`7000) of Division 3'of the Business and HEATER WALL
Professions Code,and my license Is in full force and effect
License Number Llc Class }
Poo-
Contractor' _ " Date __
❑ Plan check fee
I am exempt under Sec" 1^ °l 0
B&P C for'this reason PERMIT ISSUING FEE$ 0 i;F O
Date
�;Et_�
TOTAL FEE al_i a
`Signature PLAN CHECK APPLICANT ctZ
OWNER-BUILDER DECLARATION _&NuE
I hereby affirm that I am exempt from the Contractor's License Law NAME poll.for the following reason (Section 7031 5, Business and Professions -
Code) - ADDRESS �. , - _ (�lF IZ'—S i{I�t j `.�:�•`'-,
UAV` I, as owner of the property, or my,,employees with wages r
as their sole compensation, will do the work and,the CITY TEL NO
structure Is not Intended or offered for'sale (Section 7044Y T
Buslness'and Professions Code) OWNER ` ��`
❑ I, as owner of the property, am exclusively contracting MAIL '
with licensed contractors to construct the project (Sec- ADDRESS- \ C r,1
tion 7044, Business'and Professions Code)
CONSTRUCTION LENDING AGENCY Cp 1 TEL NO
ITY g
hereby affirm that there is a construction lending agency for CONTRACTOR
mw
the perforance of the work for which this permit Is issued — "-
(Sec 3097,Civ C) _
A y _ ADDRESS „
Lender's Name o
CITY TEL NO e
Lender s Address STATE LIC -
I certify that I have read this application and state that the above LICENSE NO CLASS
Information Is correct I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of th.Is,County to enter upon the above-mentioned
roperty r Ins coon ur eS SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLIC NT DATE '