HomeMy Public PortalAbout10545 DAINES DR_Mechanical__ WORKERS COMPENSATION DECLARATION 20-0046 DPW 9/89
hereby'affirm that I have a certificate of consent to self Insure, 76A364C ,APPLICATION FOR PERMIT LIME GREEN
,or a certificate of Worker's Compensation Insurance; or a certified 4 k HEATING-VENTILATING-AIR CONDITIONING
copy thereof rSec 3800-Lab C) R "t
'; P IicyiNo `:nC 9 d•4 6 7 7bor-pan- �R 2 Ll}��.J�C T n d =ti"
❑ , - COUNTY OF LOS ANGELES `PT OF PUBLIC WORKS BUILDING ANY SAFETY DIV.
Certified copy Is hereby,furnished
i : '
a F BUILDING
Certihed copy is filed with the co ty bwlding`Inspectio FOR APPLICANT TO FILL IN ADDRESS, 105'4 5 Daine s' DT.
department + _ (PRINT OR TYPE:ONLY)
hDate Q 7
i9 4 ` LOCALITY °'2IF . ;
-
TYPE
' ,CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST r
COMPENSATION INSURANCE , CROSS ST
'Pa a t= res
ABSORPTION UNIT,BTU ASSESSOR, s,t
(Thie,sectiorlneed not be completed rt the•work involved by the MAP BOOK PAGE PARCEL
permrt,is'for one hundred dollars($100)or less) ,„ "AIR HANDLING UNIT,CFM
DISTRICT NO y P CESSED BV - •,s
I certify,that In the performance ofAhe work for which this'permit
is Issued,'I,shall not employ any person.in any,'manner so as toBOILER�BTU • �� y:
become)s6bject to the Workers'Compensation Laws - , r
COMPRESSOR,BTU ,c
Date Applicant ' 13� APPROVALS, DATE NSPECTOR S SIGNATURE
" ' ' - VENTILATION SYSTEM i+ �- '}
{,NOTICE TO APPLICANT If,'after making this Certificate of a ROUGH *'
Exemption,�'you'should become subject to the Workers'Compensation
EVAPORATIVE'COOLER FINAL' S 9
provisions.of,the Labor'Code,'you must0orthwith,comply with such s - 2� -
,prbvisions or this permit shall berdeemed revoked P FURNACE FAU GRAVITY p' a
fir,'+' LICENSED CONTRACTORSDECLARATION ' 1 FLOOR BTU J` , VALIDATION
I hereby affirm that I am licensed und,er'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 _ z J
JL
iLicense'Number221751 Llc,Class C-20
ijc
V CO.ntract Q ow
ate R /7 d:/A d
ham exempt under Sec Plan check4fee - -,^i 7 FAL U
PERMIT ISSUING'B&P C for this reason `
Date TOTAL FEE 0� r`i��i3E-
Signature �- -TIL.1 .' - - • PLAN CHECK APPLICANT
ECL '- " + n - `
t w i ',OWNER-BUILDER DARATION
Z
I hereby,affirm that I am exempt'from the Contractor's license Law NAME'for the the followmg.reason (Section 7031 5, Business and Professions i
SCbde) „ - b4r } 1 ADDRESS Jd' ; ti Ht 1r1ICI
owner of�'theyproperty„or my:employees with wages' '
` as;their sole'compensation, will do the work and the CITY = r TEL•NO
I staucture is;,not mtended',or offered for sale_(Section'7044,
Busmess-and'Professions Code)` x OWNER -
0'r �I, as,-owner,of tRe property,�,am,exclusively contracting MAIL '
y a.
wifw-licensed contractbrsto construct the project,(Se6, ADDRESS; _I,0
4
*43 tioii 7044,Business and Professions Code)'
{;; CONSTRUCTION LENDING AGENCYx �r 11 CITY- TEL NO _71 55 Q
rt i o
I'hereby affirm that there is a construction lending agency for
the performance'of the work for wFilch this permit is issued CONTRALTO
(Sec,3097, Ci
C) T a -
.r, , . v •� � � ” ADDRESS " _
L'ender's Name
6IT,1', t TEL NO i
' San Gabrdel
Le SS
STATE ' LIC _
certify-that I have read thisapplication'and state that the above LICENSE NO CLASS _
information is'corre,! I agree to comply with all County ordinances' r_ �;•_ i
-,and State law& elating to building construction;and hereby'authonze - t
representatives of this C 'nty to enter upori.the'above-mentioned
pr erty'for InspecUo rposes �.SEE REVERSE FOR EXPLANATORY LANGUAGEF
o o
V� ,� t
J 'SIGNATURE OF ICAN OR AGENT d DATE , _ • • ` . '"