HomeMy Public PortalAbout10420 DAINES DR_Mechanical__ _ OA FRS'COMPENSATION DECLARATION 76A364C
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I'hereh�• atTi rii that I have- a' certificate of consent to self
CE -SIB(2-80) APIl— L��`? AT1 O0CI -FOR PE(�WT
insure, or a certifibate of Workers'Compensation Insurance,or x EATING=VENT( ATING-Alla CONDITIONING
a certif.;d copy therce�o�f-�(Sec. 3800,,Lab.
C.)
Policy No. om�ny COUNTY OF LOS ANGELES BUILDING AND SAFETY'
�x Certified copv is hereby furnished.
Certified copy is filed with the county building inspection BUILDING. (� '
department FOR APPLICANT TO FILL IN ADDRESS �B /�02,0 ID,:
Date Applicant (PRINT OR•TYPE ONLY) `
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ---� _ (�
COMPENSATION INSfJRANCE NEAREST }
CL
(This section need;not be completed if the work involved ABSORPTION UNIT,, BTU CROSS ST: 00
by the permit is for one.hundred.dollars ($100) or less.) DISTRICT NO PRO/CESS
0
I certify that in the,performance of the work for which this AIR HANDLING UNIT,CFM �(� y
permit is issued,J shall not ethploy any person in any manner O 0
so-as to become subject to'the.Workers' Compensation Laws. BOILER, BTU
22 j ,APPROVALS jDATjEINSPECTOR'SSIGNATURE IUDate Applicant COMPRESSOR,BTU= ROUGto
NOTICE TO APPtf,CANT If;after making this Certificate of VENTILATION SYSTEMZ
Exemption; you should become subject to the Workers' FINAL' ^ —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked'
FURNACE• • FAU GRAVITY
LICENSED CONTRACTORSDECLARATION FLOOR BTU_ �4t.4_1a f6
I hereby affirm that I am,licensed under provisions of Chapter- HEATER SUSPENDED UNIT
9 (comen�ing with.Section-7000}'0(Division,3 of the Busi-. A`_-- -WALL -
ness and Professions Code, and my license is in full force and
effect. +I
License Number d 5�J���� Lib.Class C_::�U�f
EI am exempt from the "licensing requirements as I am a
licensed architect or 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 $
Lic.or Reg No. Date :TOTAL FEE J
,HOME OWNER-BUILDER DECLARATION. PLAN CHECK APPLICANT /' ' •D I
I hereby affirm that I am exempt from-the Contractor's NAME
License Law for the followzng reason (Section 7931.5, Busi-
ness and Professions Code). ADDRESS
ElI, as owner of the property, will do the work and the CITY
TEL. NO.� � S�a
structure is not intended or offered for sale,(Section _ � ��. l 2 3 0 9 A
7044;Busmess�and Professions Code). -
Q I OWNER # .'
I, as owner of the property, am,exclusively contracting o e 0 4 1
o•
with licensed contractors to construct the project MAIL f „
(Section 7044,,Business and Professions Cade) ADDRESS 2 o,0 2 7;O Q
CONSTRUCTION LENDING AGENCY CITY TEL.NO Jo o jo 2 7 Q 0 v ,
I hereby affirm that there is a construction lending agency
for the performance of the workfqr which;this permit is,, CONTRACTOR �; , i
issued Sec.3097,Civ.C.). �C - x:9,,2 b=f8
Lender s Name ADDRESS
Lender's Address `
ZIT ,V TEL. 33 7V r r
Y,
I certify that,( have read this application arid state-that the STATE- LIC•'
above information is correct.I agree to comply with all County (CENSE NOA fJ 7,5 73 CLASS v a Q
ordinances and State-laws regulating Heating, Ventilating and
Air Conditionmg,.and hereby authorize representatives of this,"_ SEE REVERSE FOR EXPLANATORY LANGUAGE
County +; nto upon the above-menti,red property for '
wiper'Ion , pec• /y�� `
na—e of Permit'ee /Date