HomeMy Public PortalAbout9826 DAINES DR_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 8618 C(2-80) APPLICATION I� tl�tl ��
I hereby affirm that I have a certificate of consent to self"
insure, or a certificate of Workers'Compensation Insurance,of
HATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab C)
Policy No Company COUNTY OF LOS
Certified copy is hereby furnished. ANGEES
, BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspectionFOR APPLICANT TO FILL IN' BUILDING
department.
Date__ Applicant- (PRINT OR TYPE ONLY) ADDRESSIANCEPPLOR EQUIPMENT FEE,
fS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF A �I
COMPENSATION INSURANCE NEAREST }tl
(This section need.'not be completed if the work in plved ABSORPTION UNIT, BTU- CROSS ST, A- 1v �. O
by the'permit is for one hundred'do118rs'($100) or I05S.) DISTRICT NO PROC D v U
I certify that in the performance of the work fog—hich this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person n any manner Q �- 0"
so as to become subject to the W kers' Corr ensat ,n Law BOILER, BTU
�(7 ` APPROVALS DATE INSPECTOR' LU
S SIG RE U
Date_hr l_~Applicant_ r_ _ / COMPRESSOR„BTU�� G ROUGH -/£7�- (� tCL
o
NOTICE TO APPLICANT- If,after making this Certificate of VENTILATION SYSTEM r .Z
Exemption, FINAL - —
p you should become 'subject to the Workers' �
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this•permit shall be /y deemed {-
revoked. FURNACE. FAUJ'—' GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU ,
I hereby affirm•that 1,am licensed under provisions of Chapter HEATER. SUSPENDED - UNIT a
9 (commencing with Section 7000)of Division 3 of the-Busi- WALL
ness and Professions Code, and my license is in full force and
effect, u
License Number16=7/�� ►ic.Class
Ce
Viit.actor ` Daie_r�
Qi aril exempt from the licensing requirements as I am a
licensed architect,or a registered,professional engineer Plan check fee 25%of above:
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ 1
-Lie.or Reg.No Date TOTAL FEE
'HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
-License Law for the following reason (Section 7031 5, Busi- r
ness and-Professions Coda): ADDRESS ”-
I, as owner of the property, will do the work and the,
,
structure is not intended or offered for sale (Section CITY' TEL. NO
7044, Business and Professions Code) mss+ ,•. 215 6,'5A
OWNER (I, as owner of the - �
;e a, m411,
with licensed contractors to construct the project MAIL �'[�Z f �� � Iii •c °
^ (Section 7044, Business and Professions Code). ADDRESS 0 3 7 Q O
r,
CONSTRUCTION LENDING AGENCY CITY EL.NO.L�—�P� - o io,10 3 7 Q O v
I .hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR _ I
issued (Sec. 3097,Cry C). /� , r altli Q G i8,0
` Lender's Name ADDRESS A"tJ /rI A/•
Lender's Address / CITY�c�� ' - CEr EL NO.; P� '
I certify that I have •read this application and State that the [' 0
above information is correct. I agree to comply with all County LICENSE NO: V— CLASS
ordinances and• State 'aws ��ulating Heating, Ventilating and
Air C drtioning,'_ed hereby author a representatives of this - SEE R�E�VER ���RY-��Ca• ct to cute up i t abo nenUoned property for
A action p'rr ses.
Signature of 1 crmtrtee Date /