HomeMy Public PortalAbout9435 DAINES DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 /�nn (�AA FOR
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. �_ .. 76A364C' ' !r-�lh'I����AL=�TM ll—®I�'ll���IrLS'ROtfII��• LIAAE .
I hereby affirm,that I have a.certificate'of•consent to self Insure, CCE
or a,certi%c'ate-of Worker's Compensation.lnsur£nce, or a certified
' HEATING VENTILATING-AIR CONDITIONING.
copy thereof.(Sec.3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT'OFPUBLIC•WOR i; -
.Policy No , .
Company KS BUILDING AND SAFETY DIV.
❑ •,.
Certified copy"is hereby.furnlshed
❑ Certified copy is filed'with'the'county building inspection FOR APPLICANT TO FILL IN gooRE S•
department. (PRINT OR TYPE'ONLY)
' f ` �
T M J)
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•—
,ate 'Applicant LOCALITY`
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
. -
CERTIFICATE,OF EXEMPTION FROM WORKERS'
�G:r
. - ... CROSSSST:
' COMPENSATION INSURANCE ABSORPTION UNIT,BTU
a, ASSESSOR
D
(This section need not,be completed rf.the work involved by the MAP=BOOK PAGE. PARCEL
ermit'ls•'for one hundred dollars $100�or less. "'
p- ( ), )- AIR HANDLING UNIT,CFM DISTRICT:NO, PROCESSED BY
I,i ertify that-in the performance of the`work for which,this permit',. _
Is issued l'shall not employ any person In 'any manner•so as to BOILER,BTU
become subject to the Workers' Compensation Laws. ''
COMPRESSOR,BTU
• - _ A VALS - _ TU
'• '- , PPRO DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT.,.,If, after making this"Certificate of
'ROUGH,
Exempton,iyou should become.subjectto,the Workers'Compensation
provisions of the*Labor Code,'you'must;forthwith comply with such EVAPORATIVE COOLER
'
FINAL
,provisions or this,.permit+shall be'deemed revoked. FURNACE "FAU G V Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU {J112 Q A3 VALIDATION
I hereby affirm that l am licensed u.ndery provisions of Chapter 9 SUSPENDED :UNIT
HEATER:
(commencing with Section 7000) of Division 3 of'the,Business:and WALL'
Professions'Code;and,my license Is In full force and effect. .
License Number Lic.Class
D: o
Contractor Date
Plan check fee M U
1 am exempt under Sec O
B&P.0 for this reason
... PERMIT FEE-$
� 7� U
Date: : . W96; '/ - 'nFE :
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK AP_PLICANT
Ot
I hereby affirm that,I am exempt%frr
om the Contractos License Law. NAME . r ��'0 44 Z
for the following+reason (Section 7031.5,Business.andI'Professlons 'Y
Co ADDRESS it
1, as owner of;the property, or,my employees with wages
• as their sole,compensation, will do the work and the CITY yM TEL'NO. . s1'
"•struct6re.is not intended or offered for sale (Section 7044;
Business and Professions Code).. e. WNE
FTI'-, as owner o'f-tne'property, am exclusively contracting' MAIL # Ef
(3 FOOD r 4
with.licensed contractors to construct the'project (Sec ADDRESS.
tion 7044,-Business and Professions Code):
CONSTRUCTION LENDING AGENCY CITY L� TEL,NO
I.hereby,,affirm that there is a construction lending agency for CONTRALTO
the performance of the work for which this permit Is issued
{Sec. 3097, Civ.C.).
D
ADDRESS
Lender's Name
CITY TEL.NO.
Lerider's Address. STATE LIC:
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 T
representatives of this County'to enter upon the above-mentioned
p rty for inspection purp�,ts.•, SEE REVERSE FOR EXPLANATORY'LANGUAGE.'
IGNA E OP APPLICAN OR A NT DATE