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HomeMy Public PortalAbout10822 DAINES DR_Mechanical__ WORKER'S COMPENSATION DECLARATION' 76A356 DPW 9/99 _APRLICATION FOR PERMIT ���� (�����, 6A399C I hereby affirm That I have a certificate of consent to self insure. � or a certificate ot.Worker's Compensation Insurance, or a certified ._'HEATfNG -VENTILATING.•AIR CONDITIONING - Mull copy(hereof(Sec.3800 Lab. C.) • - - Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ' ❑ Certified copy is hereby furnished. - - BUILDING ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS � . ?Z /J !7- r P� 'S tie ' department, r (PRINT OR TYPE ONLY) , LOCALITY / ((r. /� Data Applicant N0. TYPE OF APPLIANCE OR EQUIPMENT FEE - - - CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST . CROSS ST. - ' COMPENSATION INSURANCE ABSORPTION UNIT,BTU - • - - (This section need not be completed if the work involved by the ASSESSOR MAPSOOK PAGE PARCEL permit Is for one hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PRocEssED ev I certify.that in the performance of the work for which this permit I e is issued, I shall not employ any-person in any manner so as to BOILER,BTU O become subject to the Workers'Compensat n Laws. - (/0 / //per t}, COMPRESSOR,BTU DitO Ly '� Applicant "''r Zi Er VENTILATION SYSTEM • APPROVALS HATE INSPECTOR'$SIGNATURE NOTICE TO APPLICANT: Ii, atter making t Is Certificate.of ROUGH Exemption,you should become subject to the Wo ers' Compensation EVAPORATIVE COOLER provisions of tliel Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVRV LICENSED CONTRACTORS DECLARATION FLOOR BTU .3 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 fullforce and effect. License Number g ? f r Lic.Class c: pppp aa.. Contractor/`XPJx �(T• / �� Date �" LI y 0 Plan check fee O I am exempt untler Sea Q B.BP.C.for this reason PERMIT ISSUING FEE C2 Date: LU TOTAL FEE - j d Signature - co A PLAN CHECK APPLICANT 4 OWNER BUILDER.DECLARATION ' I Y C.Ct.7 .yAV Z I hereby affirm that 1 am exempt from the Contractor's License Law NAME N O % l' P© ,. �t •A 'D 3707 � � 86.57 for the following reason(Section 7031.5, Business and Professions F/- Code): ADDRESS �1 � '❑ 3 b'• . Ll��� 1 ITEMS 1, as owner of the property, or.my employees with wages I /� p _ as their sale compensation, will do the work and the CITY C�—C._Ces� TEL.NO. TOTAL �{ Ick structure is not intended or offered for sale(Section 7044, ' - r Business and Professions Code). OWNER G �. �CN�; �F3.r' Lu, - CHECK 36.51 -❑ I, as owner of the property, am exclusively contracting MAIL / CHANGE .00I with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY / lLT .t I TEL.NO. QIIIjU—017L 1 1I YIYC hereby affirm that there is a construction lending agency for CONTRACTOR ' the performance of the work for which this permit Is issued ,,p. D _ (sec.3097.civ. C.). L L 1-ln ,t A• $[I-7-'4' -.1. `:AN10:p. ADDRESS /'�- I la C � Q- 6/r Lender's Name CITY•l.t^--•-'�r��l.t '" Fl. TEL.NO. Lender's Address STATE LIG' I certify thatd have read this application and state that the above LICENSE NO. CLASS G - information is correct. I agree to comply with all County ordinances _ and State laws relating to building construction,and hereby authoriie representatives of this County to.enter upon the above-mentioned - pr party f r inspection purposes. I `" - - ` R SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUFE OF AP ICANT OR AGENT DATE • - r; WORKEId'Save a certificate DECLARATION 7EA3640PW 9/89 APPLICATION FOR PERMIT UAAE GREEN 0A 6 I hereby,affirm that 1 havee certificate of consent to self insure, ' or a certifioateof Workers Coglpensation'Insurance;or a certifietl' - 'HEATING -.VENTILATING - AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) <' 'Policy NO. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.: ❑ Certified copy is hereby furnished. ❑ Certified co Is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING ;"'� PY Y 9 P ADDRESS'p 8 I T I I��'S I L • department: t. � -' (PRINT OR TYPE ONLY) , Date 'Applicant' - LOCALITY T NO. TYPE OF APPLIANCE OR EOUIPMENT FEE cM'P L CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST.. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the ASSESSOR MAP BOOK 3 PAGE Q� PARCEL OOH. .permit is for one.hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM DISTRICT No, PROCESSED BY ,l certify that in the performance of the work for which this permit r ' is issued, I shall not employ any personin any manner so es to BOILER,BTU O D become subject to the Workers'Compensation Laws. uG� COMPRESSOR,BTU - APPROVALS DATE INSPECTORJ '>ANATUflE Data Applicant j VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL. /1 77? . provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY I LICENSED CONTRACTORS DECLARATION FLOOR BTU _ VALIDATION 1 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. - tO RCPkA-C 1-4£A-rcCL. License Number Lic.Class a Contractor Date .O ❑. 1 am exempt under Sec. - 'Platt Check fee 0 r� IS 1 B.BP.C.for this reason PERMIT ISSUING FEE $ O Date: TOTAL FEE Qp. .W Signature - - .13- . OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT !/I I hereby affirm that I am exempt from the Contractor's License Law, NAME M1 D Z for the following reason (Section 7031.5, Business and Professions %t/A" 1f frt'u 111 _ Code): ADDRESS 1}(I+r$❑ Ivi I, as owner of the-property, of my employees with wages - - �p as their sole compensation,will do the work and the CITY C�t/IVC TEL.NO. VYU_W+/.d �, j17 '.�j•(,_! structure is not intended or offered for sale (Section 7044, ( �-O _ tk.ff 1 Business and Professions Code). OWNER SSMC' c t�c ❑ I, as owner of the property, am exclusively contracting MAIL - with licensed contractors to construct the project (Sec- ADDRESS TUTAL [I s 5J tion 7044, Business and Professions Code). I f I F1 J5,1.11 CONSTRUCTION LENDING AGENCY. .-' CITU TEL.NO. J t1 , I hereby affirm that there is a construction lending agency for ' CONTRACTOR• WNGE C i!1 the performance of the work for which this permit Is issuetl QW�c2, (Sec.3097,Civ. C.). ADDRESS Lender's Name _ I.7 A II I-I IIJI it ?130i i 1. CITY TEL.NO. -Lender's Address _ 1. _ _ j* ry•-1- _nill4 NII `s.l,> I certify that I have read this application and slate that the above STATE LIC, NO. CUSS information is correct. I agree to comply with all County ordinances f and State laws relating to building construction,and hereby authorize _ representatives of this County to enter upon the above-mentioned prop rt f r inspection "Pose SEE REVERSE FOR EXPLANATORY LANGUAGE aIGNA�ppPLICA AGENT DATE