HomeMy Public PortalAbout9560 DAINES DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9,69
I.5lereby affirm that I have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMIT LIME G
or a certificate of Worker's Compensation Insurance, or a certified HEATWG - VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) "
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS . BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING
department. Y (PRINT OR TYPE ONLY) ADDRESS O ,D.
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE fJ
CERTIFICATE OF•EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,.BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT;CFM
DISTRICT NO. 5ROCE D BY
I,certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU O
APPROVALS ' DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL -
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 4.6) VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that l am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
Zd
License Number Lic.Class
a
Contractor Date 0
❑ I am exempt under Sec. Plan Check fee U
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE
LU
Signature a-
PLAN CHECK APPLICANT _
OWNER-BUILDER DECLARATIONeA 114,jQ
I hereby affirm that I am exempt from the Contractor's License Law NAME fa17Y�
for the following reason (Section 7031.5, Business and Professions /�1`1 ITEMS
e)' ADDRESS _ ., TOTAL 1 1„'!'iw :1(aI, as owner of the property, or my employees with wages �r�u/ 1
as their sole compensation, will do the work and the CITY TEL.NO. CIECK 114,
structure is not intended or offered for sale (Section 7044, r.uuww``ttr�
Business and Professions Code). NER rn X71 GE
® I, as owner of the property, am exclusively contracting rAD
L '! �y
with licensed contractors to construct the project (Sec- RESS 160 ! ( e r, �UQ1 20Mi �p,��SJ�
tion 7044, Business and Professions Code). Q 1 AMil'10
CONSTRUCTION LENDING AGENCY CITY e C''� TEL.NO. ' O
I hereby affirm that there is a construction lending agency for CONTRACTOR
it ,
the performance of the work for which this permIs issued
(Sec.3097, Civ.CJ.
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
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
representatives of this County to enter upon the above-mentioned
property for i ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
8 �,5 65
SIGNATURE OF APPLICANT OFT AGENT DATE