HomeMy Public PortalAbout10709 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION
PPLIC p TION FOR PERMIT
I hereby affirm that I have a certificate of consent to self P9 /`1 YVAVE
insure, or a certificate of Workers' Compensation Insurance, ieAab4C - HEATING VENTILATING - AIR.CONDITIONING
or d certified copy thereof (Sec. 3800; Lab. C:)
CE-818(REV. 10/81)
Policy No.—Company-5 �t•�•s/.I. .
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- - BUBOING
tion department ADDRESS
q�t , II fUi f� (PRINT OR TYPE ONLY)
- 'Date Z—q—r7'; APPlicant •�� � LOCALITY,f_ it /
NO. TYPE OF APPLIANCE OR EQUIPMENT, FEE _ T ,
CERTIFICATE OF EXEMPTION FROM WO KERS' . .NEAREST
COMPENSATION INSURANCE s CROSS ST. ryi�•_
ABSORPTION UNIT, BTU
(Thissection DISTRICT NO, PROCESSED By
. need not be completed if the woik Involved by
the permit is for one hundred dollars (S100)of less.) T AIR HANDLING UNIT, CFM
I-certify that in the performance of the work for;which this,
permit is issued, I shall not employ any person in bny'manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. _ APPROVALS DATE INSPECTOR'S SIGNnTuae
Date Applicant COMPRESSOR, BTU - 3�i .✓ ROUGH 7�fb � s e...�
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL `J
Exemption, you should become,subject to the Workers'. _ _ - -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be _
deemed,ravoked. FURNACE: FAU G AVITY - h
LICENSED CONTRACTORS DECLARATION FLOOR BTU RIP 00a
I hereby affirm that I am licensed under provisions of Chapter 9 HEALER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the•Business - WALL
and Professions Code, and-my license is in full force and effect. - S
Licen_se Number2&S-PIS, v Lic. Class
V
D
ContractorDate Z-q 93 - - - 0
FJI am exempt�u rider Sec S
Plan check fee
B.BP.C. for this reason N
Date:
PERMIT ISSUING FEE $ ' Z
-
• TOTAL�FEE �[}
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm than am exempt from the Contractor's License D Y9'5 7'7 A
Law for the following reason (Section 7031:5, Business and NAME
ProfessionsCode): • • e e�e
❑ ADDRESS 8
- #'
I, as owner of the property, or my employees with _ p
- wages as their sole compensation,will dothe work and - - - - - - - • ^3.0 5 0
the structure isnot intended or offered for sale(Section CITY - TEL. NO. '/.
7044, Business and.Professions Code).
OWNER
El _I, as owner of the property, am exclusively contracting _
with licensed contractors to construct the project (Sec- MAIL - - 2,0 4—8 3
'tion 7044, Business and Professions Code). ADDRESS
.CONSTRUCTION LENDING AGENCYCIT)� � — �' TEL. NO.
I hereby affirm that there is a construction lending agency forwz � - - ,
the performance of the work for which this permit.is,issued CONTRACTOR , -
(Sec. 3097, Civ. C.). LU/•{/�� '/-f- .Q• _ _...
ADDRESS
Lender's Name -
Lender'sAddress - CITY /.y_ !}.I _ - TEL NO.��.'7
STATE YY' pp l-// - LIC.
1 certify that I hove read this application andstate that the
LICENSE NO: p �p -;CEASS.
above information is correct. I agreeto comply with all County -
ordinances and State laws relating to building construction,
nd here y authorize representatives of this Courity'to enter l
u on th above-mentioned property for inspection purposes. SEE REVERSE FOR:EXPLANATORY LANGUAGE
1 -4-a3
SignaWre of A Xlicont or Agent Date - -