HomeMy Public PortalAbout9334 DAINES DR_Mechanical__ WORKER'S'COMPENSATION DECLARATION 20-0046 DPW 9%69 /�n
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I hereby affirm that l have-a certificate of consent to self insure,' 76A364C
or.a certifid(te:of'•Worker s Compensation Insurance, or a certified �.
copy thereof(Sec..3800 Lab.c.) HEi4TING-VENTILATING-AIR
CONDITIO"I"
Policy No.` " CompanyCOUNTY OF LOS ANGELES DEPT OF`PUBLIC".WORKS BUILDING AND SAFETYDIV.El `
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APP.LICANT TO FILL INP, goDR SS'
department. - : (PRINT,ORTYPE ONLY)
Date Applicant LOCALITY'
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
CERTIFICATE.OF EXEMPTIOWFROM WORKERS; ;_ NEAREST
CROSS ST:
COMPENSATION INSURANCE: . "
ABSORPTION UNIT,BTU
(This, not be.com leted•if the work, the b ASSESSOR
( P MAP BOOK - PAGE PARCEL
permit is for,one hundred dollars($100),or.less.) s AIR HANDLING UNIT,CFM-
DISTRICT NO. PROCESSED eY''
(.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' p
become subject.to.the Workers' Compensation Laws.'
COMPRESSOR,BTU
'-i: •" .., a.• - - - 'APPROVALS :DATE ',INSPECTOR'S SIGNATURE
Applicant
VENTILATION SYSTEM -
NOTICE'TO APPLICANT:'If', after. making•this Certificate of ROUGH
Exemption,you should become subject tb'the Workers'Compensation, EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL (•L
provisions or this permit shall be deemed revoked. FURNACE.' ;FAU GRAVITY '
i;X VA {DATION
LICENSED CONTRACTORS DECLARATION FLOOR - BTU
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
Contractor= Date :0
Pl
❑ ;
exempt under Sec,'
-' an checkfee
I am •'
•
U
B&P.C.for this reason PERMIT ISSUING FEE O
Date:
O
w.T
Signature PLAN CHECK APPLICANT "r
OWNER-BUILDER DECLARATION
Z
hereby affirm that I am exempt frorn the Contractor's License Law NAME
forthe;following reason:(Section 7031.5, Business and Professions
' Co.r,T1 `•. ADDRESS .;- M y i
.� I; as owner of the property, or my employees with,wages
as,their sole compensation, will do the work and the CITY TEL NO. -- - '-
structure is not interided or offered for sale (Section 7044, 1T�—�
Business and Professions Code):' OWNER _
❑ [,.as owner of the property, am exclusively contracting MAIL i HL $
with licensed contractors to construct the project (Seo:. ADDRESS
tion 7044, Business and Professions Code). -
. - CITY .TEL NO '. .. '
CONSTRUCTION LENDING AGENCY
I hereby affirm that,there'is.a construction lending agency for'
the performance of the'work for which this permit is issued CONTRACTOR
(Sec..3097, Civ.C.). D,
fes/ ADDRESS `
Lender's Name / s I f t! s "� f i
CITY TEL.NO. S`•. 1 f-1:.i'
Lender's Address STATE LIQ,
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 z
representatives of this County to enter upon the above-mentioned
property for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
�►_.. -
AT OF APPLICANT OR AGENT— ATE -