HomeMy Public PortalAbout10526 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or led copy thereof (Sec 3800, Lab C ) 76A364C
r tyle t' 20-0046 DPW 9/88
Po'llcy o lhr'�/ Company1�/�I�
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
FA Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
} on department ADDRESS
(PRINT OR TYPE ONLY)
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.N Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE 4. &MLOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
• COMPENSATION INSURANCECROSS ST
(This'sectlon need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY '
the permit is for one hundred dollaAIR HANDLING UNIT, CFM
rs ($100) or less.)
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 become'subject to the Workers'Compensation Laws BOILER,-BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU D ROUGHA, rld
ONOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM / FINALIII
Exemption, you -should become subject to the Workers' C•�
Compensation provisions of the Labof'Cbde, you must forth- EVAPORATIVE COOLER V L A
r, with comply with such provisions or this permit shall be deem-
edrevoked ) I FURNACE •FAU
LICENSED CONTRACTORS DECLARATION FLOOR - BTU }
I hereby affirm that I am-licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business HEATER WALL
and Professions Code,and my license is in full force and effect
License Num er Lic Class d, O , O
4 V
Contractor&U102 Date IOC
❑ I am exempt under Sec>.
. Plan check fee v
B&P C for this reason CL
H
v,
Dare PERMIT ISSUING FEE $IN Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031 5, Business and NAME
Professions Code) r
❑ I, as owner of the property, or my employees with ADDRESS ;
wages as their sole compensation, will do the work and y•f s
the structure is not intended or offered for sale'(Section CITY _ TEL NO �fi.-) A
7044, Business and Professions Code) • - OWNER =rte 7
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 1
tion 7044, Business and Professions Code)
ADDRESS _
CONSTRUCTION LENDING AGENCYCITY TEL NO r )I'i�A' 52 m 00
j hereby affirm that there is a construction lending agency for _ �• �r iHECK
the performance of the work for which this permit is Issued CONTRACTO
(Sec 3097, Civ C ) adZnCHANE
i
ADDRESS - e iF1t11Ri3L.
Lender's Name9AJI
CITY TEL NO
Lender's,Address �C �— l li)i i_ l� I f,-, •STATE LIC
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I certify that I have read this application and state that the LICENSE NO C ASSOY
above Information is correct I agree to comply with all County
ordinances and State laws relating'to building construction, `
and hereby authorize representatives'of this County to enter
upo he above-mentioned property for inspection purposes - -'-
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature of Applicant or Agent Date Os
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