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HomeMy Public PortalAbout9909 DAINES DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT . 76A364C I hereby affirm that I have a certificate of consent to',se.Y'insure,�� - O��''certificate of Worker's Compensation Insurance, or a certified _ HEATING-,YENTI`LATING -AIR CONDITIONING cdpy thereof(Sec 3800 tab C 1 „ h T-- L� ad �/ tel/ ,'• '. Policy Nob © Company !Ti COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY_ DIV. �0 'Certified copy is hereby furnished ° Lg Certified co Is filed with the count 6uddm Ins ectlon FOR APPLICANT'TO FILL IN BUILDING PY Y 9' P ADDRESS department ••� - - (PRINT OR TYPE ONLY) � `N -. BI r _ .• Date Z 2 �—�PPhcant s. LOCALITY , NO TYPE OF APPLIANCE OR EQUIPMENT FEES �� ' CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST:� " ABSORPTION UNIT BTU ASSESSOR, (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) t.^ AIR HANDLING UNIT,CFM DISTRICT No PRocEsseDeY certify that'in the performance.of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensatlon Laws COMPRESSOR,.BTU �� V - �j /� / APPROVALS DATE IN SIGNATURE Date r pp VENTILATION SYSTEM •NOTICE TO APPLICANT If, after making t is Certificate of _ ROUGH Exemption,you should become subject to the'Workers' Compensatlon EVAPORATIVE COOLER ? provisions of the Labor Code, you must forthwith comply with such FINAL l' provisions or this permit shall be deemed revoked ^4 FURNACE, FAU-' GBAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU �� 'G� VALIDATION I herebyaffirm that I am licensed under provisions,of Chapter 9 SUSPENDED - •-,UNIT fy (c.r`mencing with Section 7000) of Division 3 of the Business and HEATER WALL O Professions Code,and my license is In full force and'effectACCT. a (� gdj tGn _ 3308 =. il� License Number 7 7 - Lic Class y , 1 'ITEMS s a Contractor Date 1= 9� TOTAL_ 11.x- :L 0 ' r! I am exempt under sec Plan check fee - - - CHECK 114e 10 1= B&P C for this reason " ` - PERMIT ISSUING-FEE$ CHANGE Q�U Date TOTAL FEE - _ 4.. f�,� e W Signature 0000-0001 2/29/96 Z + ' - PLAN CHECK APPLICANT 10(3 1 M 7=44 OWNER-BUILDER DECLARATION "' "" _ A I ' I hereby affirm that I am exempt from the Contractor's License Law NAME _ for the following reason (Section 7031'5, Business and Professions Code) ❑ w ADDRESS - - I, as owner of the property, or my employees with wages f as their sole compensation', will do the,work 'and the CITY TEL NO structure is not intended'or offered for sale (Section 7044, - - Business and Professions Code)••• OWNER _ ❑ I,`as ownei of the property, am.exclusively,contracting MAIL with licensed contractors torconstruct the'prolect (Sec- ADDRESS .0 � '' tion 7044, Business and-Professions Code) CITYT� TEL NO����l� CONSTRUCTIOWLENDING AGENCY - / " I hereby affirm'that there Is a'construction lending agency for "" :• - the performance of the work for which this permit is issued CONTRACTOR (Sec 3097,Civ C) .f ADDRESS 3 7 Ay. Lender's Name /� - . CITY�. TEL' NOg /ij%C/. __ .. _ ....,.•,•_ Lender's Address STATE -LIC I certify I have read this application and state that the above LICENSE NO ' CLASSµL:`�L',d Information Is correct I agree to comply with all County ordinances and State'laws relating t0 budding construction,and hereby authorize -� fepresentatives of this County t0 enter upon the above-mentioned, i gaATE or I peck purposes' SEE REVERSE FOR,EXPLANATORY LANGUAGE SIF ARLICANT OA AGENT •-� DAA _