HomeMy Public PortalAbout9314 DAINES DR_Mechanical__ DEC
TION
Worm that
I have a cerci cafe of corse 6=�11�1l-L��Cl�=111 0 N FOR ll-15RIIVUO U
I,_herel�y affirm that I have a certificate of consent To self
-insure, or a certificate of Workers' Compensation Insurance, HEATING !VENTILATING - AIR CONDITIONING
or a certifie copy thereof (Sec. 3800, Lab. C. 76A364C "
7574 �cP /✓c P�I11�y CE-81.8(REV. 10/81)
Policy No. fCoryfurn COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building.inspec- FOR APPLICANT TO FILL IN - BUILDING
tion department. ADDRESS, //VC�,f
(PRINT OR TYPE ONLY)
Date
�~�j Applicant rt LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENTFEE
CERTIFICATE OF EXEMPTION FROM WORKERS'; NEAREST
COMPENSATION INSURANCE CROSS ST.
(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 ✓C (e b
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPEC S SI ATURE
Dare Applicant COMPRESSOR, BTU ROUGH
/ Q
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 VALIDATIO
with comply with such provisions or This permit shall be
deemed revoked. FURNACE: FAU G VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU v- 0 G G
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED - UNIT(commencing.with Section 7000) of Division 3 of the Business. WALL
and Professions Code, and rhy license is in full force and effect.
License Number [ 63l3� Lic. Class 3
Contractor "oN"-o�' Date ~ J .0
❑.. ;:•, N
I am exempt under Sec. W
Plan check fee IL
8.8P.C. for this reason OA
PERMIT ISSUING FEE $ Z
Date: '
Signature TOTAL FEE Sd ;2 2 9.Q3 A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D # o o o o o
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):. o o 3(15.0
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and o. o,0 3 0,5 0
the structure is not intended or offered for sale(Section CITY TEL: NO.
7044, Business and Professions Code). 09, 12-85
OWNER �r 114s �1//i/ �✓
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code).
. 19 ADDRESS
CONSTRUCTION LENDING AGENCY3 r�
CITY e M (Jf �. TEL. NO:
I hereby affirm that there is a construction lending agency for D
the performance of The work for which this permit is issued CONTRACTORN�
(Sec. 3097, Civ: C.).
y �� Ii/Ct/Yr
Lender's Name ADDRESS Y C�(� L'
CITY FA ' TEL. NO. / 7 r d X
Lender's Address 4p 0,/,L.
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. C/o 3 CLASS-
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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE- --
Signature of Applicant or Agent Dote