HomeMy Public PortalAbout10910 DAINES DR_Mechanical__ 'WORKER'S thatIhaveacNSATIONDECLARATION 2a-0041C 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, "
or a certificate of Worker's Compensation Insurance, or a certified ' HEATING-VENTILATING- AIR CONDITIONING -
copy thereat(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 builcing inspection .FOR APPLICANT TO FILL IN BUILDING
. department. y (PRINT.OR TYPE ONLY) ADDRESS
Data ApplicantLOCALITY
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE i ;
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST _CPW __
CROSS ST.
COMPENSATION.INSURANCE _ _. _ >> - - ABSORPTION UNIT,BTU _ --' `..._'• - ___. _ _-_.._ -
This section need not be completed if the work involved by the ASSESSOR
( P MAPBOOK PAGE PARCEL
permit Is forone hundred dollars($100)or less.) AIR HANDLING UNIT,CFM - -
Disraicr ND. Paocssseo er ,
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 r.
become subject to the Workers'Compensation Laws. ' o
L COMPRESSOR,BTU
'- - AFFaovALs. DATE INSPECTOR SIGNATURE
Applicant VENTILATION SYSTEM
NOTICE TO.APPLICANT: H, after making this Certificate ofEVAPORATIVE COOLER
ROUGH
Exemption,you should become subject to the Workers' Compensation
,provisions of the Labor Code, you must forthwith comply with such FINAL - '
provisions or this permit shall be deemed revoked. I 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 i HEATER: WALL
Professions Lode, and my licenseis in full force and effect. ..
License Number Lia Class
Contracloi Date '-' ..... ... - 0
Plan check fee - J c -
❑ am exempt under Sec. / n1.`1 .a IM:
B.BP.C.for this reason _ PERMIT ISSUING FEE _;?,i c O
Date: TOTAL.FEE O' ' W
Signature - (-
PLAN CHECK APPLICANT - U)
OWNER-BUILDER DECLARATION 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 - 1 ITEM-'
cDd ADDRESS TOTAL 52 e Off.
'. I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. .:HECK e2'05
-
structure is not intended or offered for sale (Section 7044, nCHANGE
Business III,
Business antl Professions Code). OWNER Chid
,L'6 0YE I•tfl
ILTvJy 1, as owner of the property, am exclusively contracting MAIL Cyr •t IV 11��
with licensed contractors to construct the project (Sec- ADDRESS Jl j (,� /-Y�V^ f' •t
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY 94`Q r L— 2.9 NO. Z I -
hereby affirm that there is a construction lending agency for - - D �.1�4 1' A.110��✓`•
the performance of the work for which this permit is issued CONTRACTOR
(Sec.3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO. -
Lentler's Address -
I certify that I have read this application and state that the above SICENSE NO. CLASS
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 _
property for inspection.purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
SIGNATURE FAPPLIC NT AGEFj �DA '