HomeMy Public PortalAbout10645 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION
PPA ICA TION FOR PERMIT � L g/2/ /!�
L`hereby affirm that I have a certificate of consent to self /'Y IL /`Y (� (� EVA .l (U
insure, of a certificate of Workers'Compensation Insurance, 7aABaac - HEATING - VENTILATING - AIR CONDITIONING
nor a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No.—Company
Certified copy is hereby furnished. - COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN: - BUILDING
10
tion department. (PRINT OR TYPE ONLY) ADDRESS
Dote 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 o15TRla NO. �PROCESSE lir
the permit is for one hundred dollars ($100)or les .) X
I certify that in the performanc of th work for which this AIR HANDLING UNIT, CFM t OV
permit is issued, I shall not emp y any erson in ny anner
so as t0 come the or e 'Comp all L BOILER, BTU APPROVALS DATE ECTOP'S SIGNA,TIIRE
Dat pylic nt COMPRESSOR, BTU r u�-/ ROUGH i 1
NOTICE TO APPLICANT If, to oking this. ice a of - VENTILATION SYSTEM FINAL
Exemption, you should bec a subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIC AT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VIN
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that lam licensed under provisions of Chapter 9SUSPENDED UNIT_
d
'(commencing with Section 7is of Division 3 of the Business HEATER: - Y
NIT—
and Professions Code myy licen�se WALL
/y'�/in full force an of ct. f he O /e, (1
L '` d
License -�'—LTt. Class �/7 D 0Cantrac or / O
❑ F
a x mot under Se W
Plan check fee w
B. P.C. for this reason'
Date: �6 95.7/1
PERMIT ISSUING FEE $ Z
Signature
' TOTAL FEE 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # o e •,e 6 8
I hereby affirm that I am exempt from the Contractor's License D )( e 4 4 5 O
Law for the following reason (Section 7031.5, Business and NAME e
Professions Code):
El1, as owner of the property, or my employees withADDRESS - o s o 4 4 5 O x x
wages as their sole compensation,'will do the work and CITY TEL. NO. O S O 2 t 8 7
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER I/
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL MAIL5 �•
tion 7044, Business and Professions Code). ADDREST '
CONSTRUCTION LENDING AGENCY CITY i TEL. NO. �1-J
I hereby affirm that there is a construction lending agency for D '
the performance of the work for which this permit is issued CONTRACTOR
Wizaft(Sec. 3097, Civ. C.).
ADDRESS L-
Lender's Name /Jfi
CITY TEL. NO. .. _
Lender's Address
STATE ' LIC.
I certify that 1 have read this application and state that the 'CENSE NO. � LASS
above in 'motion is< 'act. I agree to comply with all County
ordinan s and Stat lows relating to building construction, _
d e.eb authori a re wtotie �Coumytoenter
pa t l b ntir Cou p see. SEE REVERSE FOR EXPLANATORY LANGUAGE
If App icant o_49 e to - '