HomeMy Public PortalAbout10712 DAINES DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION
PPLIL ICA TION FOR . PERMIT
.I hereby affirm that I have a certificate of consent to se)f • P9 P9 OCI �V�
insure, ore certificate of Workers;Compensation Insurance - - ..;.HEATING '- -VENTILATING AIR CONDITIONING
or a certified copy thereof'(Sec 3800, Lob. C.) 76A3&C-
/
CE818(REV. 10/81)
Pollli1 93'J'
icy NCompany 5- T1c li"G 42iA
Certified copy is hereby furnished COUNTY OF LOS ANGELES __ . . BUILDING AND SAFETY
�" - _
,Fky� Certified copy,is filed with the'county building inspec-, t FOR APPLICANT TO FILL IN BUILDING D ��
mon deparr-timeent. , (PRINT OR TYPE ONLY) ADDRESS
Date'.�T -.�"a Applicant " LOCALIT
L NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �)
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO 55 ST. _ ur
(This section need not be completed if The workinJolved by . - ABSORPTION UNIT, BTU DISTRICT [�OCESSED
No. BY
fhe.perrnif Is for one hundred dollars' ($100)or less.) 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 any manner,
so as to bbecohr e subject to the Workers'Compensation
�Lows. BOILER, BTU APPROVALS o TE INSPECTOR' SIGNATURE
Date4_7Applicant ✓E `u `' /rN/�d COMPRESSOR, BTU - ROUGH i
_NOTICE TO APPLICANT: If, after making this Certificate of - VENTILATION SYSTEM. FINAL or
you should _become subject to the Workers'
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER ALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU • GRAVITY -- _
LICENSED CONTRACTORS DECLARATION 'S FLOOR BTU '
hereby affirm that I am licensed under provisions of Chopter 9 SUSPENDED UNIT_ -
'.HEATER: WALL '
'(commencing with Section 7000) of'Division 3 of the Business
and Professions Code,and
/� li
mylicenseis in full force and effect.
License Numbe;d(27WTO _ Lic Class' D V
Y
Contractor Date �L
❑ � _ _ - ~
I'am exempt under Sec 0V+
Plcn check fee - a•
0.8P.C. for this reasonN
- PERMIT ISSUING FEE $ - - Z
Date:
Signature - _ TOTAL FEE
OWNER-BUILDER DECLARATION- PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAMED :2 3 2.9,la A '
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
s $
wages as their sole compensation,wil Ido the work and (J - " - e
the structure is not intended or offered for sale (Section C"Ern r t TEL. NO. L - ,? .3'D,1Jr
w
7044-Business and Professions Code). -M - - - -
OWNER No ,^ • 30..50
❑ 'I, as owner of the property, am exclusively contracting r l
with licensed contractors to construct the project (Sec- MAIL -7 5 ,� I3.�0�7,-84..
tion 7044, Business and Professions Code). ADDRE55
In CONSTRUCTION LENDING AGENCY Cd - TEL NO: - —'
I hereby affirm that there is a construction lending agency for -' ,
the performance of the work for which this permit is issued - CONTRACTOR
(Sec. 3097, Civ. C.). - _
. . ADDRESS !S;-Cl 3 7 - ..-. . _ _
Lender's Name
Lender's Address' CITY r' - ,- Y . EL. NO.
STATE
TIC
I certify that L have read this application and state that the _ LICENSE N J y� ; CLASS � V• _. . . _ ..
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
u n the above- entioned property for inspeclion purposes. SEE REVERSE FOR EXPLANATORY.LANGUAGE ._
Signature of Applicant or Agent Dale