HomeMy Public PortalAbout10820 DAINES DR_Mechanical__ 17,thatI have PENSATION DECLARATION 7GA346 DPW 9/89 a'\`TPL�CATION .FOR PERMIT
1 hereby off irm.that I have a.certificate of consent to self insure,-'
.or a certificate o1 Worker's Compensation Insurance, or a certified - - - HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3600 Lab.C.). - - -- -
Policy No. Company - COUNTY OF LOS ANGELES DEPT OF'PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby'fumn Shed /� ^
❑ Certified 477
copy is filed with the county building inspection , - FOR APPLICANT'TO FILL,IN pooRE88 D 2Q /'(l, S
department. (PRINT OR TYPE ONLY) q q
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LOCALITY �(„1 L I.= �( `# �(
Date.-- Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
_
iCOMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST_. -" -
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE
permit is for one'h on d red dollars($100)or less.) - PARCEL
AIR HANDLING UNIT,CFM DISTRICT NO, PRocassED BY -
certify that in the performance of the work for which this permit -is issued, I Shall not employ any person in-any manner so as to BOILER,BTU n
become subject to the Workers' Comp nq satiori Laws. - - - ,v? �"
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COMPRESSOR,BTU - tea S �2wL
✓X!� IlCanl U - APPROVALS DATE INSPECTOR'S SIGNATURE
p _( VENTILATION SYSTEM
NOTICE TO APPLICA NT: Ifefter makin his Certificate of ROUGH -
Exemption,you should becomesubject to theWorkers' Compensation EVAPORATIVE COOLER - -
provisions of the Labor Code, you must forthwith comply with such FINAL _/ 3
,provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVLTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU S VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect. -•T
License Number 363( Lic.Class L 2
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Contractor Pot Fit Fet `((Da7e `1-[— 93 a a
El am exempt under Sec. - Plan check fee - ANT.r -- -C 0
1.
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B.&P.C.for this reason PERMIT ISSUING FEE$ OQ
Date: TOTAL FEE 1 ITEM= U
Signature I&AL 71 --25 d
PLAN CHECK APPLICANT Lt Z
OWNER-BUILDER DECLARATION (.ntt.�� 71..^_iC Z
I hereby affirm that I am exempt from the Contractor's License Law NAME O `l �QL r- _ u tt� _
for the following reason (Section 7031.5, Business and Professions �f _ I CHANGE •)130
Code): ADDRESS 3
❑ I, 2s owner of the property, or my employees with wages �����lll / p IT'"
as their sole compensation, will do the work and the CITY (.Y'-�a✓LE'A-C-C � _ )lZpT .NO. fJ/J2j-/—�dd - (.IDD I-0001 ?I 1/93
structure is not intended or offered for sale (Section 7044, . 1 4 _ "__... o n
Business and Professions Code). OWNER ' - 1 V(r /ti' l]at 1 AM 10:18
❑ 1, as owner of the property, am exclusively contracting MAIL '
with licensed contractors to construct the project (Sec- ADDRESSU-
tion 7044, Business and Professions Code). 4 '
CONSTRUCTION LENDING AGENCY CITY ri�404�6-�T,,p'3TEL.NO y ,
I hereby affirm that there is a construction lending agency for i" D -
the performance of.the work for which this permit Uis issued CONTRACTOR keq (P—r 4 PAX al ^
(Sec.3097,Civ.C.)._
ADDRESS
Lender's Name / � � p ,
- CITY � tic TELNO: )n
( 7y- fe'yt -.
Lender's Address ,,QQ
I certify that I have read this application and state that the above LICENSE NO. % , CLASS - 20,
-
information is correct. I agree to comply with all County ordinances
End State laws relating to building construction,and hereby authorize • ' '- - - - '-
representatives of this County to enter upon the above-mentioned . .
TV,for inspection purposes. — I _ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATGREO APPLICANT OR AGENT ✓ DATE