HomeMy Public PortalAbout10633 DAINES DR_Mechanical__ S ORKERS'COMPENSATION DECLARATION APPLICATION A PPLIC TION FOPERMIT
MIT y
'I he affi.m that I have a certiFlcate.ofconsenf to self /'Y R U(
insu a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or iifizd,�/pyereof (Sec. 3800, Lab. C.) r
CE-BIB(REV. 10/81)
Ocy LCompanyQ/1L!!1L— COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.(I
Certified copy is filed with the county building ins ec- - FOR APPLICANT TO FILL IN BUILDINGp 7
ti ndepartment. ADDRESS /11)411"32
(PRINT OR TYPE ONLY)
Date _V` ?Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE --
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROLE ED BY
the permit is for one hundred dollars ($100)or less.)
ov
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM s
ev
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws. ' BOILER, BTU , �LAPPROVALS - DATE INSPECTOR'S SIGNATURE
Date L1
Applicant (' COMPRESSOR, BTU i y ROUGH
NOTICE TO APPLICANT:'If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' 7
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT
with comply with such provisions or this permit shall be
deemed revoked. I FURNACE: FAU GRAVITY /
LICENSED CONTRACTORS DECLARATION FBTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
'(commencingHEATER: WALL with Section 7000) of Division 3 of the Business �
and Professions Code, and my license is in full force and effect. d
License Number o3 7• J Lic Glass C7 (� D V
Contractor 60D,A/ND 2 Date ��3 �E� 7 9 7.7 A °C
I am exempt under Sec. W
Plan check'fee 'I�• 3 Q 5,0 w
B.BP.C. for this reason- PERMIT ISSUING FEE j
Date: _ •.:e le 3 0,5 Q Z
• Signature � TOTAL FEE i
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT O9.2 3 .. 8 7
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): -
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale.(Section
7044, Business and Professions Code).
OWNER 7
❑ I, as owner of the property, am exclusively contracting -
with licensed contractors to construct the project (Sec- MAIL n./N
Don 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY �( TEL. NO.
I hereby affirm that there is a construction lending agency for ` l D
the performance of the work for which this permit is issued- CONTRACTOR QN 2 7v�[
(Sec. 3097, Civ. C.). - _ �/'•
Lender's Name ADDRESS �Iyjfl IV, -A, y� "
CITY7—c-
-r TEL NO. I(_. S _
Lender's Address "
STATE 9 LIC. n
I certify that I have read this application and state that the LICENSE NO. Q .3 CLASS C,Xo
above information is correct. I agree to comply with all County '
ordinances.and State laws relating to building construction, _
and hereby authorize representatives of this County to enter - -
up the above-m d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Applicant or Agent Dare -