HomeMy WebLinkAbout02_12_1987 - 21015 PATHFINDER RD (4) WORKERS'COMPENSATION�ECLARATION APP"CATION FOR PERMIT �
I hereby affkm that 1 hove a cerfificate af consenl fo self � ,
insure,or o certificate of Workeri Compensarion�nwrance, - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) � 76A36aC . � .
CE�-818(REV.10/81) .' . .� . . . . �
POolicy No%�Z76�n'�ompany .�1I,�'�� �. . . � .
Certi(ied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� ��.Certified copy is filed with�he county buil 'ng i � � - �� FOR APPLICANT TO FILL IN � -� - . BURDwG c� :p
tion departmenf. (PRINT OR TVPE ONLY) ADDRESS � d/cJ / �c
� Date�J�Z—�� APPIicaM- � - LOCntI7Y m P�
NO. NPE OF AP%.IANCE OR EOUIPMENT � FEE
CERTIFICATE OF EXEMPTIO OM KERS' . NEARE57
� � COMPENSATION SURA CROSS ST.
(Thk ieeNon need not be eompleled i e work Imolvod by ABSORPTION UNIT,BTU' � o�sraicr No. va seo a
- 1ha permlt Is for one hundrad dollors(f100)ar lass.) L��(� /� �b �
I certify thal in fhe�performanCe of the work for which this � A�R HANDLING UNIT,CFM L'
permit is is5oed,I shall nof employ ony penon in ony manner . _
' so as to betome su6jeU ro rhe Workers'Compensation Laws.._ BOILER,BTU � nvvaovn�5 �ATE INSPECTOR'S SIGNATURE
Date Applicant � COMPRESSOR,BTU ROUGH � �
NOTICE TO APPLICANT: If, after making this Certifimte of� VENTILA7ION SYSiEM FINAL
� Exemp�ion, you should become subjecL to the Workers'
Compensarion provisians of the Labor Code,yoo most forth- EyqppRqTIVE COO�ER ' VALIDATION
with romply wlth such provisions�or this�permif shall ba .
deemedrevoked. � � � PURNACE: � iAU_GRAVIN- ' .
. � LICENSED CONiRACTORS DECLARATION . F�ooR� BTu � �
I hereby affi�m that I am licensed under p�ovisrons of<hapter 9 HEATER: SUSPENDED UNIT �— - •
'(commencing with Secfion 7000)of Division 3 of fhe Business WALL
and Professions Coda,and my Ikense Is in full force and effect� � . � . � � � - � �� � � y
. . ..
Litense Nomber�b���� Lic.Ciass l3� - . - � - ��--� - �-- � , V
GC
/J��G C�Gsu� �.G,C�.� iG!/ O
Contrat�or Date �'���� . ... ... - �-.
❑ I am exempt under Set. � � ... _ . . . . V
Plan check fee °�
� B.BP.C.for this reason - - y
PERMIT ISSUING FEE S /
Z
� � TOTAL PEE p 3 5 2 0 A
Signature - . � � �
� R-B ER CLARATION PIAN CHECK APttICANT - . �r• • • •.�S
I hereby offirm t at I om eze t from the CoNracror's License
low for ihe foltowing reason(Seclion 7031.5, Business and NAME , �� �!G r.y � • '2 Q 5� �
Professions CodeJ: - -
❑ I, os owner oi the property,or my employees wilh ADDRESS( - • • •2�.5�� .
� woges as their sole compensation,will do tha work and . ��ry - TEt.nt0. �_� �,,.� 0 2� 3—$7
' the strvcture is not intended or offered for sale(Section
7044,Bosiness and Professions Code). ---- � �+--- -�-- - -- - � �
� OWNER �id / O � . .... .
❑ I,as awner of the property,am exdusively contracling MAII- " s �
with licensed contractor5�o Construct the project(Sec-- AODRE55 7���Z /�G / JDn/
tioo 7044,Business and Professions Code).-� , _
CONSTRUCTION LENDING AGENCY - - dn -/ ��� �� - �� iet:NO.- - � -� � � . .
I hereby affirm that Ihere is a construction lending agency for
�he performonce of�he work for whith this permit is itsued-� �ONTRACTOR - �G L �/ � ' �j{�ll-- - ,_
(Sea 3097,Civ.C.). ,,1 �j y� - - � - . . -.. ..
, _.. ' -
,.;.... , - � .
. ADDRESS '�D U�. GC. t O`U _ ... ...._ . ... . ._ . . - _. . . _ . . .
Lender's Name y -
� � . . CITY_�(JH.� � � . _ TEL_NO,_�7I"�G _. .._.. _ . ..
tender's Address
$iATE C UC. �?
I certify fhot I have reod this applimtion ond stote Ihot the UCENSE NO. O� CIASSY � -� �-- - � - �- . - � � . - - � - �
obove Information is correct.I a e to comply with oll Co�ny
ordinances and Sta�e laws r ing 10 boilding construclion, _ � .
and hereby authori e re ent ves of.ihis Counry to enter � � � �� � - � ��� � � - �� � -� � �
opon the ob ve- n) d p erty for inspeU�on purpozes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _
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