HomeMy Public PortalAbout10640 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION
APPLICATION
IL PPL P9 ICA IVY
TION FOR PERMIT
I he�aby offirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 76A364C - HEATING -VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab: C.) CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OFLOSANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUDDING // ,/(DT r-�`- � )rrtt
tion department. (PRINT OR TYPE ONLY) ADDRESS Qf7•yy tAl NGS
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OENSATIEXEMPTION FROM WORKERS' NEAREST " ,/ LI C)
COMPENSATION INSURANCE - � CR0555T. dLY W/IV VrJ.
(This section need not be completed if she work involved by
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) - -
s AIR HANDLING UNIT, CFM
er )vf
I ctify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
sous to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVA1.5 DATE SP TOR'S SIGN URE
`
Datpplicant COMPRESSOR, BTU s 00 400O ROUGH
e A _
NOTICE TO APP (CANT: If, .after making thisLkeificati of VENTILATION SYSTEM RNAL
Exemption, you should become subject to thef Workers' -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GR ITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTU . 00
I hefeby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
'(commencing with Section 7000) of Division 3 o the Business _ ALL
and Professions Code,and my license is in full force and effect. n D Y
O
License Number "I Class _ D V
K
Contractor Date - O
❑ V
am exempt under Sec. W
Plan check fee us
8.8P.C. for this reason' - us
Date: PERMIT ISSUING FEE $ Q_15D - Z
Signature TOTAL FEE y
OWNER-BUILDER DECLARATION - PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License - D -
Law for the following reason (Section 7031.5, Business and NAME -
Professions Code): -
IL`N I, as owner of the property, or my employees with ADDRESS 9'7 a 4 A
wages as their sale compensation, will do the work and e e 8
the structure is not intended or offered for sale(Section CITY TEL NO. .%I^e Fi 3 9,2 5
7044, Business and Professions Code).
OWNER AAZ KIM a —U 39.25'
❑ I, as owner of the property, am exclusively contracting a•e �
with licensed contractors to construct the project (Sec- MAIL /a 64® . I 0 52 6"88
tion 7044, Business and Professions Code). ADDRESS '�
CONSTRUCTION LENDING AGENCY CITY Teml_rc OT TEL:NO. $_ V
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR `1 '
(Sec. 3097, Civ. C.). D✓�"'� D -
ADDRESS
Lender's Name -
CITY TEL NO
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I dgree to comply with all County
ordinances and State laws relating to building construction, _
and hereby authorize representatives of this County toenter - - - "
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY-LANGUAGE _
S
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Slgnatur�i o gent Date