HomeMy Public PortalAbout10632 DAINES DR_Mechanical__ RKER'SaOe a certificate
DECLARATION 20A31HIC W9/89 —APPLICATION FOR PERMIT U� E GREEN
70A 6
I hereby rm that I have a certificate of consent to self insure,
or a cerQflicaierof Wo'rker's Compensation_Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof((S/See.3800 Lab.C.) ` • - - .. u
Policy No./�0q r - SCompony S,'aTC Fu. - COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
ISI Cenified copy is hereby furnished.
ICI. Certified copy is filed with the county building ins FOR APPLICANT TO FILL IN ADDRESS
action ,,} p
P ADDRESS O�_ Z QfJ7A� DR
.,department .) � (PRINT OR TYPE ONLY)
Date 17 6, Applicant r`/.Tr ' �AI LOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
- CERTIFICATE OF EXEMPTION FROM WORKERS'
CROSS ST. �( / i b M EAll
COMPENSATION INSURANCE
r ABSORPTION UNIT,BTU ASSESSOR
(This section need not completed the work Involved by the - MAP BOOK PAGE FPARCEL
permit is for one hundred
etl tlollars($1000)or less.) AIR HANDLING UNIT,CFM
OISTn'FT NO. PFCCE%EG BY
I certify that in the performance of the work for which this permit '
is issued, I shall not employ any parson in any manner so as to - BOILER,BTU
become subject to the Workers'Compensation Laws. G '
COMPRESSOR,BTU
P,PROVALS DATE INSPECTnS GNATi, E,
O ' SI
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 lj�-2 -g[q
provisions or this permit shall be deemed revoked. FURNACE: FAUG V //
LICENSED CONTRACTORS DECLARATION,- FLOOR BTU b� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_ _
(commencing with Section 7000) of Division 3 of the Business and HEATER:" WALL
t/OProfessions Code,and my license is in full force and effect.
License Number ,37Z Llc.Class /• - Q E
�/ D ACCT.: >
•ConlractorA416 oeLrr4„�s—z�te 1-17-96 3303. 109.90 0
L
I am exempt under Sec. Plan check fee - 1 ITEMS
B.&P.C.for this reason 'PERMIT ISSUING FEE $ 73L) O
TOTAL . 1D'9_90
Date: TOTAL FEE e, 90 CHECK 109.90 w
Signature CL
CHANGE .00 m
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '
- Z
I hereby affirm that I am exempt from•the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS D 0000-0001 1/17/96
I, as owner of the property, or my employees with wages - 4298 : 1 AM1O:32
as their sole compensation; will d0 the work and the CITY TEL.NO. l.7Cr
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER LooG rH C�
I, as owner of the property, am exclusively contracting MAIL /yam, -
with licensed contractors to construct the project (Sec- ADDRESS 1532- -r> 7P IC3 PJZ
tion 7044, Business and Professions Code). ��> / '
. CONSTRUCTION LENDING AGENCY CITU 7�-lT TEL.NO }r,`7.5'_ b b
here
by affirm that there is a constructions perm agencyissued
for CONTRACTOR •,ILO
the eyo affirm
t of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name r ,/ p
CITY TEL.NO. / JY,1 O DS'
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. a 3�� CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representa fives of this County to enter upon the above-mentioned
property fp nspeCtion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '
/- 746,
SIG VR170F APP VM OR AGENT DATE