HomeMy Public PortalAbout10614 DAINES DR_Mechanical__ WORKERS'COMPENSATION DECLARATION
APPLICATION FOR PERMIT
I hereby affirm that I have o certificate of consent to self '
nsore,'or a certificate of Workers' Compensation Insurance, 76 ABC - - HEATING - VENTILATING - AIR CONDITIONING
or a certified cop there (Sec. 3800, Lab. C.
���.�+ ,ter^,�• �0 v� CE-8181REV. 10/81) - - n_ -
,Palicy No •�1.4 Compan IT'r COUNTYOFLOS ANGELES /' C BUILDING AND SAFETY
❑ Certified copy is hereby furnished.w
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN _ BUBDING
�Ilion djjja�rtment. (PRINT OR TYPE ONLY) ADDRESS I y
Date ACL Applicant GtrC/ ' LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST.
COMPENSATION INSURANCE CROSSST.
(This section need not be completed if the work involved 6y ABSORPTION UNIT, BTU D6TRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)of less.)
I certify that in the performance of the.work for which this AIR HANDLING UNIT, CFM ,
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. . ILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Dote Applicant COMPRESSOR, BTU �� Go .� ROUGH �� x
NOTICE TO APPLICANT:df, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with' comply with such provisions or this permit shall be !/
deemed revoked. FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR - BTU a
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_HEATER: WALL
'(commencing.with Section 7000) of Division 3 of the Business Y
and Professions Code,and my license is in full forceand effect. d
License Number �� 26� SZ Lic Class C:) D V
rK
Contractor 6. C_S_ Date, O
H
❑ am exempt under Sec. - W
Plan check fee - d
N
6.8P.C. for this reason- - PERMIT ISSUING FEES Z
Date:
Signature - TOTAL FEE ' e'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - �.� 812 0 A
I hereby affirm that I am exempt from the Contractor's License D #{ o oto 0 0 8
Law for the following reason (Section 7031.5, Business and NAME - t r
Professions Code): -.-
( ADDRESS ,2.010 2 0 Or
❑ I, as owner of the property,'or my employees with
wages as their sole compensation,will do the work and . to.o a 2 0.5 Q_
CITY TEL. NO
the structure is not intended or offered for sale(Section ` U
7044, Business and Professions Code). - - --OWNE0 0t7—8 4
El1, as owner of the property, am exclusively contracting R - -
with licensed contractors to construct the project (Sec-- MAIL ' -
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY - CITTEL. NO. _
I hereby affirm that there is a construction lending agency for - D - - -
the performance of the work for which this permit is issued CONTRALTO ✓ -'
(Sec. 3097, Civ. C.). "� -
S i's•s�! s ,
Lender's Name ADDRESS n
CITY T / TEL. NO.
Lender's Address 1 L
I certifythat I have read this application and state that the STATE LIC. ^
PP LICENSE NO. ',L - CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, '
and hereby out a representatives of this County to enter - -
ypa�lin abpurposes.o - en CTed property for inspection S
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent ' Date - - - -