HomeMy Public PortalAbout9561 DAINES DR_Mechanical__ WORKER'S COMPENSATION DECIARATION 200046 DPW 9/89 APPLICATION FOR PERMIT 'L'�E GREEN
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¢I hereby affirm that I'have a certif4:ate of consent to self Insure,
or a certificate of Worker's-Compensation Insurance, or a certified _ _ w
Py HEATING. VENTILATING AIR CONDITIONING t,
co therreoof(Sec 3800 Lab [qC p v s
+PolicyNd.JRD�?7't �pa'ny ,,' _ ; e. "- •t FE
{ COUNTY OF LOS ANGELES"' DEPT OF PUBLIC.WORKS, BUILDING AND SAFETY DIV.
❑; Certifiedcopy is hereby furnished
t
❑ ' FOR APPLICANT TO FILL IN BUILDING ti "
Certified copy is filed with the count budding ins ction ADDRESS J �j r r t z w/L;
department "``, (PRINT OR TYPE ONLY) «, ,
LOCALITY
` ,Date' 2 A Iicant-
PP NO JYPE OF'APPLIANCE OR EQUIPMENT "FEE,'
CERTIFICATE OF EXEMPTION FROM WORKERS' , '4 NEAREST+ f r
•+ '
'OR', _ CROSS ST n
COMPENSATION INSURANCE . . r TggSORPTION UNIT,BTU ' v >^
"• ASSESSOR- t
(This section need not,be completed if the work involved•by the MAP BOOKt #'PAGE PARCEL
"permit Is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM-_ DISTRICT NO PROCESSED BY,
•-
I certify that In the,performance of the ork,for which-this permit
wr r -
Is issued,.) shall not employ any person In any manner so as to., BOILER BTU
tb/ect to the Worker
become sus' Compensation Laws
t� 'COMPRESSOR,BTU',
•APPROVALS DATE INSPECTORS SIGNATURE
•'Date -'Applicant + VENTILATION SYSTEM S
NOTICE TO APPLICANT, If,'after""making this Certificate,of * ROUGH:' + t
Ezemtion,you should'become sub ect to the Workers'Compensation
P Y, 1 P EVAPORATIVE COOLER
provlslons,of the Labor Code,-,yo6'must forthwith comply with such "•' FINAL
provisions or this permiL shall be'deemed revoked n' FURNACE' FAU GRAVITY /
e LICENSED CONTRACTORS DECLARATION, FLOOR BTU Z, VALI ATION '
>.I'hereby•affirm that I,am licensedunder, HEATER provisions of Chapter,9 t, SUSPENDED UNIT'
e
(commencing with Section "
7000) of,Division 3 of the Business'and t WALL p
Professions Code,and rrilicense is In full force and effect U
,�.. ACCT.a•
'License Number Lie Class '/� { 30J
114.10>
Contractor '4 Date i ITEM r a - O
_ ❑ Plan check.fee �. TOTAL �. ,m t� Q
am exempt under Sec
B&P C for this reason PERMIT ISSUING,FEE$ - CHECK M
Date TOTAL FEE 0 w CHANGE . W
` '� Signature . ,� - , -" •.' ' .,-�-� ,' l .. ' `_ �• � fA
OWNER-BUILDERDECLARATION PLAN CHECK APPLICANT �_ t
`I hereby,affirm that am exempt from the Contractor's License Law NAME �p O 1 vt,t 1a� Z
for the following,reason (Section'7031 5, Business and Professions - i' r'J, ''f, ~Ovrt7 1` A1t:7-17
Code) ADDRESS
"❑; I, as;owner.of'tlie'property;or my employees with wages
as their-'sole compensation, will do the work and the CITY -TEL'NO' ' <� •f
s.. , structure-Isnot intended or-offered for sale (Section 7044;- „
t j ' Business and Professions Code) OWNER
t-
s❑ I,,'as owner of the property,am exclusively contracting
MAIL
with licensed contractors to'construct the,prolect (Sec- ADDRESS .S I 2 + ; f-,fy '
tion 7044,Business anis Professions Code)
CONSTRUCTION LENDING AGENCY r CITY T /t TEL NO
7
-
I'hereby affirm that there Is a construction lending'agency for r T -
the` CONTRACTOR �,. , + g
performance of the work for which this permit Is,issued - �,
(Sec 3097,Civ C) w t ''• ;: r, 4
ADDRESS, ' f • �'.� •�_ _ +
Lender's Name
. CITY ,+ - TEL
Lender's Address r STATEr LIC^ s
I certify that I have read this application and state that the above LICENSE NO x D CLASS
Information is correct I agree to comply with all County ordinances u l,' •K. �;
- and State laws relating to building construction,and hereby authorize
representativeZpon
County to enter upon the above-mentioned
ro f mur oses p p p , 'SEE REVERSE FOR EXPLANATORY LANGUAGE P y ,
- _ l'�_ -_ • '
SIGNA E OF L ANT OR AGENT a DATE