HomeMy Public PortalAbout10918 DAINES DR_Mechanical__ TION
WORKER'S thatICOMPETdSAcateofconsen to 76A34C 9/89 APPLICATION FOR..PERMIT I� ME . GREE,
0-00 4C
I hereby affirm that I have a certificate of consent to sed insure,
or a certificate of Worker's Compensation Insurance,.or a certified - HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3000 Lab. C.) - - --
Policy No. -.Company .COUNTY OF LOS ANGELES.. - - DEP.T,OF PUBLIC WORKS BUILDING AND SAFETY DIV..
Certified copy is hereby furnished,
❑ Certified ca Is tiled with the county building inspection - FOR APPLICANT TO FILL IN BUILDING JO
departmentPy y g p, (PRINT OR TYPE ONLY) '. ADDRESS
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE LOCALITY
,CERTIFICATE OF.EXEMPTION,FROM WORKERS' NEAREST
CROSS ST
BCOMPENSATION.INSURANCE _ ..v.r-.. ABSORPTION UNITp BTU '_-- -— - ' -- - - --- _ - - -
This section need not be completed if the work involved b the ASSESSOR` ` '
( P y. " MAP BOOK �^ ,. PAGE O� PARCEL O�9 '
permit is for one hundred dollars($100)orless.) AIR HANDLINGUNIT,CFM
DISTRICT NO PROCESSED BY
1'certify that in the performance of the work for which this permit - -
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
became subject to the Workers' Compensation Laws - j - `, �Pd �Q�'.' - G +fir•
COMPRESSOR,BTU �O O!_
APPROVAL$ OATS NBPECT.nc sloWUPE
Dale Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificatebof ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
you must forthwith comply with such FINAL
provisions of the Labor Code, y p y _
provisions or this permit shallbedeemed revoked.. FURNACE: . •FAU GR VITY
LICENSED CONTRACTORS DECLARATION / .FLOOR BTU �0 - VALID TI
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.
License Number Lic.Class - OD 9r?JL.T
_ I-
1J6 � i1�r.i'� a0
Contractor Date - -
��• Plan check fee LIE U
I am exempt under Sec.- '" TCLTPE 1 14 e •ic O
s aP.C.for this reason PERMIT ISSUING.FEE $ /�lfJ ,.
.Date: I_I1F4�,. 14.1 U
LU
Signature TOTAL FEE CHAh17t ,o W
OWNER-BUILDER DECLARATIONPLAN CHECK APPLICANT Z
P hereby affirm that I am exempt from the Contractor's License Law NAMED (tl X11):_)})�I 1 if�,' S/'.`
for the following reason (Section 7031.5, Business and Professions.
•Code): ADDRESS
'1011? 1 AF:t I1 I C.
❑ ' 1, as owner,of the property, or my employees with wages
- as their sale compensation, will do the work and the CITY r TEL.NO..
structure'is not intended or offered for sale (Section 7044,
Business and Professions Code). WNER' 1
I, as owner of the property, am exclusively contracting MAIL -with licensed contractors-to construct the project (Sec- ADDRESS
'-tion 7044, Business and Professions Code)..
CONSTRUCTION LENDING AGENCY CITY` TEL. -
Ihereby affirm that there is a construction lending agency for CONTRACTOR 10
the performance of the work for which this permit Is issued
(Sec. 3097,Civ.C.):
ADDRESS
Lender's Name "
.. CRY TEL.NO:.
Lender's Address STATE LIC.
1 certify that I have read this application and state that the above LICERSE NO. CLASS
information is correct. I agree to comply with all County ordinances -
anci State laws.relating to building construction,andhereby authorize
representatives of this County to enter upon the above-mentioned
propar for i 5 No purL�d� SEE REVERSE FOR EXPLANATORY.LANGUAGE
GNATURE OFA PLI ANTOR AGENT 0A