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Home My Public Portal About10851,10850 DAINES DR_Mechanical__ affirm WORKER'S IhCOMPENSATION DECLARATION 763346 DPW 9189 APPLICATIOWFOR PERMIT L��l EU GREEN; ' 28004 C 1 hereby affirm that have a certificate'of consent to self insure, ora certifical2 of Worker's Compensation Insurance, ora certified -' . 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.- p,2 Certifietl co is tiled wilhlhe count builtlin 'ns ection FOR APPLICANT TO FILL IN - BUILDING' �D �i PY Y P epartme t. (PRINT OR TYPE ONLY) ADDRESS- - Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT LOCALITY.f FEE E FICATE OF.EXEMP FROM WORKERS' NEAREST COMPENSAT .INSURANCE - - - - CROSS OR - --.-- - ABSORPTION UNIT,BTU - ASSESSOR ' (This section need not be co leted if the work involved by the MAP BOOK PAGE `[PAL .permit is for one hundred'dollars($100)or less.) AIR HANDLING UNIT,CFM ' DISTBICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I'shall not,employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation laws. COMPRESSOR.BTU - Dale Applicant VENTILATION SYSTEM ABBRovA15. DATE INSBBciogs slsNATURB _ _y NOTICE TO APPLICANT: If, after making this Certificate of - ROUGH - Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER - provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked., FURNACE: FAU_GRAVITY - ' LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_ ? ` (commencing with Section 7000) of Division"3'of the Business and HEATER: WALL 6 - Professions Code, and my license is in full fdice'and effect:' - �1GiYD7 License Number Lic.,Class13 ' Contractor a�(< L '�kjlr� Date _ - ❑ I Plan check fee - U am exempt under Sec. _ -, 8.8P.C.for this reason- PERMIT ISSUING FEE$ L�;�'S - - _ _U Dale: TOTAL FEE �! - UJI d Signature -- - - (q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - • Z I hereby affirm that I am exempt from the Contractor's..License Law NAME for the following reason(Section 7031:5, Business and Professions T Cade): ADDRESS ACC- T .. ❑ '' ` I, as owner of the property, or my employees with wages rr`` rr11ff as their sole compensation,will do the work and the CITY TEL.NO. .r.rll7 h'v•Vll structure is not intebded or offered for sale (Section -ITEMS 7044, - j I Business and Professions Code). . :" 1 . OWNER 1 GG Jd F] TI, as owner of the property, am exclusively contracting MAIL TOTAL 8 m QQ with licensed contractors to construct the project (Sec. ADDRESS / •' - C-rFCK - 4u 7 .i tion 7044, Business and Professions-Code). '• . a4V CONSTRUCTION LENDING AGENCY CITY TEL'.NO. 5 - CHANGE hereby.affirm that there is a constructionlentling agency for CONTRACTOR- the performance of the work for which this.permit Is issued (Sec 3097,Civ.C.). rr��rr�� /p , .: ,. ADDRESS - `�/ :?' __ T �IIJUIJ—VVO1 :��.9/92 Lender's Name - CITY - TkN 404. '. i AM11e04 . .Lender's Address LIC..' I.certify that I'have read this application and state that the above LICENSE NO. `` Lc5ps 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 upon the above-mentioned propeg mspec' purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE SIGNA P Ir AIT ' WORKER'S COMPENSATION DECLARATION 46 DPW 91e9 APPLICATION FOR PERMIT �� GREEN76A3 I.hereby affirm that a have certificate of consent to self insure, 7MS64C or a certificate.of Worker's Compensation Insurance, or a certified ' HEATING -VENTILATING-AIR CONDIT16NING copy thereof(Sec.3800 Lab,C.I " 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 county building Ins eciion FOR APPLICANT TO FILL IN BUILDING S / PY 9 P - ADDRESS department. (PRINT OR TYPE ONLY) Date Applicant - LOCALITY NO. 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 MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)Or less.) AIR HANDLING UNIT,CFM DISTRICT No. PROCESSED BY I certify that in the performance of the work for which this permit - - is issued, I shall not employ any parson in any manner so as to BOILER,BTU become subj t to th. orkers'Compensation Laws. s _ �O N—a-yr•� COMPRESSOR,BTU - APPROVALS DATE INSPECTOR'S SIGNATURE are 11,17 Applicant VENTILATION SYSTEM NOTICE TOAPPLICANT: If, after making this Certificate of ROUGH - Exemption, youshould become subject to the Workers'Compensation EVAPORATIVE COOLER provisions oLthe Labor Code, you must forthwith comply with such FINAL / _ "-- provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY' LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPEND UNIT_ (commencing with Section 7000) of Division'3 of the Business and HEATER" WALL D O'np o Professions Code,/and my license is in full force and effect. , License Number ��"��`A��'�� /�� Lic.Class 'Z:�9 o Contractor l,CCG�/?� Q�Date �/ D 0 ❑ - Plan check fee U I am exempt under Sec. t= B.&P.C.for this reason PERMIT ISSUING FEE $ B-O � Date: TOTAL FEE p.o W SignaI OWNER-BUILDER DECLARATION PLAN'CHECK'APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME D for the following reason (Section 7031.5, Business and Professions (3ode): ADDRESS • "(;'i ❑ k_{. .r I, as owner of the property, or my employees with wages __• as their sole compensation, will do the work and the CITY _ TEL.NO. 7 structure is not intended or offered for sale (Section 7044, - - Business and Professions Code). OWNER �' _ 1 1-0F. ❑ I, as owner of the property, am exclusive) contracting Tl P P Y• Y 9 MAIL tOTAL 25 00 with licensed contractors to construct the project (Sec- ADDRESS - CHECK tion 7044, Business and Professions Code). CHECK ttLtl-1 CONSTRUCTION LENDING AGENCY CITY - TEL.NO= 3 S"//,� t.Hrytil,E ihe performance of the work for which this permit is issued CONTRACTOR hereby affirm that there is aconstruction lending agency for .r D . . (Sec.3097,Civ.C.). . . ADDRESS Lender's Name CITY '� TEL.NO _iii :1 �.. . . All 11) ql l Lender's Address STATE LIC n�f - I.certify that I have read this application and state that the above LICENSE NO. � CLASS information is correct. I agree to comply with all County ordinances - -and State laws relating to building construction,and hereby authorize representativesA this County to enter upon the above-mentioned propert for' ection purposes. f _ SEE REVERSE FOR EXPLANATORY LANGUAGE " GNATUR OF APPLICANT OR � ENT r