HomeMy Public PortalAbout10603 DAINES DR_Mechanical__ WORKER'S COMPENSATION PENSATIONDECLARATION 7204)046 6A3640PW9/89 APPLICATION FOR PERMIT �� E GREEN
I hereby affirm•dhat I have a certificate of consent to self insure, 76A364C
or a eenificate of Worker's Compensation Insurance, or a certified - HEATING-VENTILATING—AIR CONDITIONING
j hereof(Sec.3800 La�y1b.C I ,
lc C3 oKC pany L r 'COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. 0
Certified copy is hereby furnished.
❑ Certified co is filed with the nt buildin ins ection .FOR APPLICANT TO FILL IN' - BUILDING I o/ /T i��.
PY Y P ADDRESS ` (o 0
d partment (PRINT OR TYPE ONLY) LA I
Date Applicant _ LOCALITY�J , t
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAPBOOK PAGE.. PARCEL
permit Is for one hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM
palelm W. PflOCE55E0 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. - �f-
COMPRESSOR,BTU O
APPROVALS OATE INSPECTOPIKNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this 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
LICENSED CONTRACTORS DECLARATION FLOOR BTU -1 O VALIDATION
I hereby affirm that I am licensed under provisions Of Chapter 9 SUSPENDED UNIT_ �p
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. ACCT.A
License Number��/—t I/� Lia Class �a �l ` D 3303 80.50
C 1 ITEMS a
Contracto Date 1 L - TOTAL $p.EOr
❑ I am exempt u der Sec. Plan check fee . CHECK U
' .SO¢
BAP.C.for this reason PERMIT ISSUING FEE$ p - CHANGE ,OO�
Date: TOTAL FEE p W
SignatureCL
0000-0001 2/12/96
pW
N CHECK APPLICANT /1'�/fjb Z
- OWNER-BUILDER DECLARATION PLA �
I hereby affirm that I am exempt from the Contractor's License Law NAME 'ten v D 4815 1 PM12:49
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESSL` -
❑ I, as owner of the property, or my employees with wages �''L-'�1
as their sole compensation, will do the work and the CITU TEL.NO J
cj
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner,of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS i AJ e.
rofessions Code).
tion 7044,CONSTRUCTION PLENDING AGENCYCITY 0 '+ J J V—✓1 / 1 '
TEL.N
I hereby affirm that there is a construction lending agency for CONTRALTO D
the performance of the work for which this permit is issued
(Sec.3097, Civ.C.).
ADDRESS 1
Lender's Name
CITU TEL.N0.t4
Lender's Address STATE LIC.
1 certify that I have read this application and state that the above LICENSE NO. bZ.` CLASS `V -
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize '
entatives of this County to enter upon the above-mentioned
ro r pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - --
SIGNANPE OF AP �N?OR AGENT ` OFTE