HomeMy Public PortalAbout9844 DAINES DR_Mechanical__ -; 'WORKERt COMPENSATION DECLARATION,- 20-0046 DPW 9/89
76A364C _ APPLICATION FOR,PERMIT LIME,, GREEN
I,hereby,affirm,that•I'hive,a-certificate of consent to self Insure,
ora certrficate'of'Worker's ComperisatlonInsurance, or a certifiedY• HEATING-VENTILATING-AIR CONDITIONING
-copy thereof(Sec 3800 C'ab'
'Policy No ,Company, ' COUNTY OF LOS ANGELES t DEPT OF PUBLIC WORKS BUILDING AND SAFETY,DIV. '
❑° Certified copy Isyhereby furnished
"Ce rfied co is�filed wrth,th_e count building inspection � FOR APPLICANT TO'FILL IN � BUILDING,
P y 9 P ADDRESSl�
de artmen i {" k (PRINT OR TYPE ONLY) ;-
{' f _
c^� LOCALITY
Dat '` ' Appli n NO TYPE OF'APPLIANCE OR EQUIPMENT, »FEE
~ N St,
CERTIFICATE OF EXEMPTION FROM WORKERS'-, CROSS ST
COMPENSATION INSURANCE! sD'4 ABSORPTION UNIT BTU ' ASSESSOR
"+•(This section need-not 6e completed If the vioik Involved by_the MAP•BOOK PAGE",,;, PARCELz
P ermit is for one hundred dollars,($100)or less.) AIR HANDLING,UNIT,CFM
DISTRICT NO, e w PROCESSED BY °-1
I ceilify,that mthe-performance of,the work for which this permit•
' Is'Issued,;I,ishall not'employ any person In any manner so as to BOILER,BTU 3.��`'. x 'l:.•
become subject to the Workers' Compensation Laws' , -S• 3'
r E COMPRESSOR,BTU
Y~ ' 4 6. 'r' '•-°„ t'i ,- �, "APPROVgLS,f DATE,{3; Zi INSPECTOR'S SIGNATURE
Applicant VENTILATION 4' VENTILATION SYSTEM, „
NOTICE TO'APPLICANT,If, after making this ,Certificate of _ ROUGH'' " t
Exemption,you should'becomesubct jeto the Workers°Compensation EVAPORATIVE COOLER FINAL
provisions of'the;Lab6r•Code,you must forthwith comply with such f,
'
.provisions or this permlLshall be deemed revoked ,FURNACE FAU ^"
' LICENSED CONTRACTORS DECLARATION .tet � FLOOR _ BTU � : - _'•,r..•_ " I 1
,I .hereby affirm that lkam licensed underprovisions of Chapter 9 'SUSPENDED-
-UN IT
HEATER
(commencing witti Section 7000),of Division 3 of the Business and, WALL
Professions Code,'arid my license Is in full force and effect 4t'
i• HLlcenseNumb% /. Lic<Class Ci �1, O I— 1 xr• �?
dL
+t,. • ,• � a .-. �^y. ,» '' >t` TO.
Contracto Date
b Plan check-fee
I'am exempt under Sec ' R W
B&P C for�fhle reason PERMIT ISSUINGFIEE;$ :r
`Date, TOTAL FEE 0 ,",. +% , p< j' �W
a.
Signature t'." •(/1
4 PLAN CHECK-APPLICANT n'
'` >> ",OWNER-BUILDER DECLARATION'
I hereby_afhrrri that Gam exempt from the�Contracto�'s License Law NAME �', L,;��' ��;;,� i 3=�- '�
; 'foi the,following reason.(Section 7031 5, Business and Professions »
Code) > t b ADDRESS,:
❑ I,`as'ownerof'the,property,,or,my,employees'wrth wages
as their sole compensation,;will"do the work_and'the CITY TEL",NO i
structure isnot intended ror offered for sale (Section 7044. '3
Business and'Profe'ssions.Code) OWNER
r- ,".
" ,❑ ,1„as ov;ner.of'the property;-am-exclusively contracting MAIL // z+ d,` rt"�, t}'�ai1 < ^�:c' •�:I :�
with licensed contractors to,construct the project (Sec-- ADDRESS T ° ?y`` '�• ' '-�
tion 7044,"Business,and Professions Code)
CONSTRUCTION LENDING AGENCYCITY +' TEL NO __•__1>' '
u h ? ";r : u �_I3! I t—'1[[�6E pp qq ��
Ir i ., _ 'trJ't _ "_r.
hereby affirm that there Is a construction lending agency.for , ! ,i ,`�4, ti, - .*
the performance of the,work for which-+this permit Js issued CONTRACTOR p _ r,r�t,�
(Sec 3097,Civ C) f: A-i,i� ::. T_ } __ ": '•1 v+t IL,
{ y
ADDRESS
Lender's Name
, v CITY EL�D
Leride�'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 4'
and State laws relating'to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned t' '
"�SII�IIAIIE
'o Hsps tion rposes r - SEE REVERSE,FOR EXPLANATORY LANGUAGE' r +'
O APPLICANT OR AGENT - rD E
4 .�' `