HomeMy Public PortalAbout10620 DAINES DR_Mechanical__ ( ,WORKERS' COMPENSATION DECLARATION ' APPLICATION Ltl IM1�V9 ICA ION FOR PERMIT
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I.her31"iy affirm that I. have'b cerci{ieate of daysent f0 self P9
iAsure, or a certificate of Workers' Compensation Insurance, HEATING - .VENTILATING - AIR CONDITIONING
or a certified copy copy thherre/pf (Sec. 3800, Lab. C.) )� 76A364C
Policy'No.t UQ h47(er'ompany ��Q �/w"-r/• !p-�46 DPW 9/88',
Certified copy isT.her_eby furnished. COUNTY OF LOS ANGELES- BUILDING AND SAFETY °
Certified copy is�filed•wlth the county building inspec- FOR APPLICANT TO FILL IN 'BUILD NG
'tion department. r ADDRESS 7 1�U ._s
.In1� t ``( I(, t (PRINT OR TYPE ONLY)
Dc • 1 Z _ Applicant A I Lw1 iL /+I .- LOCALITY
NO, TYPE.OF APPLIANCE OR EQUIPMENT - FEE
t CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST -
COMPENSATION INSURANCE` ' I - CROSS ST.
ABSORPTION UNIT, BTU
,t (This section need not he died dollars
the work iess.) ,d by DISTR¢T No. D _/ aRoc e eY
}hepermit is for one hundred dollers ($100) or less.) • �1�"
I certify that in:the'performance of the workrfar which this FAIR HANDLING UNIT, CFM J
ED
is issued, I shall not employ any person In any manner (r• —
so as to•become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date. Applicant '1" - COMPRESSOR, BTU 44. 00 0, (/ ROUGH
NOTICE TO APPLICANT:'1f, after making this Certificater,of - VENTILATION.SYSTEM FINAL
Exemption, 'you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ;EVAPORATIVE COOLER ALIDATION
with comply with such provisions or this permit shall be deem- '
.ed revoked: FURNACE: FAII—GRAVITY
• LICENSED CONTRACTORS DECLARATION FLOOR BTU
I-hereby affiim-that I am licensed under provisions of Chapter 9HEATER: .,SUSPENDED_UNIT WALL 1 '0
_ i O -
'
(commencing with Section 7000)'of Division 3 of the Business and Professions Cogde,an!dd my license is in full force and effect.
License Number Lic. Class -
Contractor X411 I L' MRL Date � ' �'� '" r'
,E 1 . . exempt under Sec O
• PlanW
_ check fee u
6.8P:C. for this reason - CL
V1
• . . t " PERMIT ISSUING FEE $ - -
Dade:' . Z
TOTAL FEE
Signature -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
I hereby off irm,that I am eaerript,from the Contractor's License D
.Law for the following reason (Section 7031.5, Business"and NAME
Professions Code): -
I, as.owner of the property, or my employees with ADDRESS - - - -
wages as their sole compensation, will do the workandy
-. the structure is not intended or offered for sole(Section CITY- - . TEL Ni A{;{, t
7044,..Business and Professions Code). ,:,
,OWNER 30 5i l
F. 1, as owner of the property, am exclusively,contracting - ��
with licensed contractors to construct the project (Sec- MAIL .1-ITEMS
tion 7044, Business and Professions Code). ADDRESS.
_- CONSTRUCTION LENDING AGENCY CITY TEL..NO. TOTAL . 40- 50
I hereby affirm that there is a construction•lending agency for CHECKthe performance of the work for which this permit is issued CONTRACTOR 40.50
(Sec. 3097,"Civ. C.). CHANGE - r
ADDRESS
Lender's Name -
CITY TEL NO. rt�-f 1 Lender's Address '- STATE - 'LIC. ' -- E�IJJV'I10u1 11/27/89
1 certify that I have read this application and.state that the LICENSE NO. CLASS 711]4
above information is correct. I agree to comply with all County 1 AM11:011•
ordinances and State laws relating to building construction,
and hereby outhoriie representatives of this County to enter
upon1 above-mentioned property for inspection purposes. "-' - • - - --• - - • -
- SEE REVERSE FOR EXPLANATORY LANGUAGE -
Lh
Signature o Applicant or Ag t Date - -
• , - - �s