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HomeMy Public PortalAbout9304 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 Policy No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY El Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY)- Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. S N (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM ` 0 permit is issued, I shall not employ any person in any manner BOILER, BTU d So as t�come subject to the Worker ' Camp Satlon Laws. APPROVALS DATE INSPECTOR'S SIGNATURE (�/�{ ! 9 COMPRESSOR, BTU �� ROUGH e Appl ican NOTICE TO.APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' - Compensation'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or.tkis permit shall be deem- � ed revoked. ' FURNACE: FAU Y r( FLOOR BTU O 0, 9 LICENSED,CONTRACTORS DECLARAT{ON Thereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. / G L O License Numb �Lic. Class , a O Contra Date 46 40 —?2. V ElI am exempt under Se O Plan check feeu _ w B.&P.C. for this reason. PERMIT ISSUING FEE $ 6,9 � i �CT. Z Date: TOTAL FEE Signature3307 37.[10 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ; TTEMS I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME TOTAL 37 = 00 j Professions Code): OI, as owner of the property, or my employees with ADDRESS CHECKt 3f 7.00 wages as their sole compensation, will do the work and CITY TEL. NO ' CHANGE the structure is not intended or offered for sale Section 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting MAR l3le 'l� lI27F''`I� with licensed contractors to construct the project (Sec- .r: tion 7044, Business and Professions Code). ADDRESS {{C�y _ CONSTRUCTION LENDING AGENCY CITY- TEL. NO. E 8 1 H`i1J : 41 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR v o � (Sec. 3097, Civ. C.). ADDRESS11111112110-0 o s Lender's Name TEL. Lender's Address I certifythat have read this application and state that the STATE LIC. pP LICENSE N Z / CLASS a above 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 upo t abo me ned pr erty for inspection purposes. �2�� -SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure of Applicant or Agent Date ©s