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HomeMy WebLinkAbout1306A (7) WORKERS'COMPENSATIONDECLARATION � APP"CATION FOR PERMIT � I hereby affNm thol I hove a cerlifitate of consenr to self , . i�ure,,or p ceriifim�e o(Workers'Compensotion lnsumnce, - - HEATING - VENTILATING - AIR CONDITIONING or atert edaopy th eof(Sec.3800,Lob.C.) 76A36aC . w�Q1014111� - � �CE-818(REV.10/91) - . . ... - . . P�oUcyNo. Company �I�'fMWls �=vAD . _ � � . . . Certtfted copy�s he�eby furnished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY ,.� Certified copy is(iled wiih tha county 6oilding inspeo- FCR APPLICANT TO FILL IN BU�tD�NG tion department. � - ADDrtE55 � ��7 3 �R�-IF��D�� � � (PRWT OR NPE ONLY) oare �a-/6-97 APPlicanl M• E. S • �ocnun O i�mon0 gR�. , Cfl • NO. TYPE OF APPIIANCE OR EQUIPMENT� FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE [.b CRO55 57, (Thls sectlon naad nof ba campbted tf iha work Involved 6y � /+BSORPTION UNrc,BTU ��i o00 �� DISTRICI NO. GROCESSF r � fhe permtf is for ona hundrad dollars(SIQO)or Iosa.J / App o� � � I cerfify ihat in the per(ormance o k�for which ihis AIR HANDLING UNIT,CFM i S : permit is issued,I shall no1 e y ony person in any manner BOItER,eTU so as to become sobjec the Workers'Compensation Laws. nvvaOva�S DA7E INSPECTOH'SSIGNATURE . - � Date PPlitaM . . . COMPRESSOR.BTU ROUGH � � NOTICE APPLICANT: If, after making this Certifica�e of VENTiLATION SYSTEM ' FiNAt Exem on, yov�should�become sobjed to the Workers' Co ensation provisians of the Lobor Code,yov most forth- EVAPORnTNE[OO�ER VALIDATION w' comp�y wilh such provisions er this perm�� shnll be deemedravoked. � � -- . FURNACE: FAU_GRAVItY � � LICENSED CONTRACTORS DECLARATION . FLooR eTU - - . I hereby affi�m that 1 arti licensed under provisions of Chopter 9 HEATER: SUSPENDEO UNIT_ ��- , - . . j '(commencing wifh Setlion 7000)of Division 3 of�he Bus�ness WA«� and Professions Code,ond my license is In full force and effect. - - � . � � �3��Q(�a 0. . License Nomher 355968� i;�,aa,s [-Zp . - - - - O . . , #• .�• • •�} � V = Conrracror M.�. s• Dote Ib—/(—�� � ❑ -' O�- I am e>empt under Set.� ' � ����"� uVi � Plan check fee �Q� o_g� H 8.8P.C.for this reason' ' PERMIT ISSUING FEE 3 /o S� z Date: s.a�a��p - TOTAL FEE $7� � y OWNER-BUILDER DECLARATION PIAN CHEIX AVMiCAM � . . � - I here6y a$irm that I am exempt from ihe Conirot�or'S Licensa , � taw for the folloWing reason(Sedion 7031.5, Business and NnME � � ' . - Pro/essions Code): � � . , . ❑ �I, os owner of the pr y, or my employees with ADDRE55 � - �wages as iheir so mpensation,will do the work and . � the struUur ' nor intended or offered for sole(Secrion Cltt . 7Ei.NO. _ 7044,B ness and Professions Code]. � � - - - �� - OWNER �G C+W dQT �O I�C�K � ❑ �I s owner of the properly,�am exdusively contracting with licensed conrracto�s to consrruc�the project(Seo- DDRE55 f-18�12 � � rv.�iTcNFLC� � �o�l � - � tion 7044,Bosiness ond Pro(essions CodeJ. - CONSTRUCTIONLENDINGAGENCY " � ��n' ��V1Jy� C�-• TE��N��-q�9��p0 � I hereby affirm that ihe�e is o mnstrutlion lending agenty for , the pe�formance of 1he work for which this permit is issued - cot�ienCioR m EGH• F-NER6 -S S'!�I'hS (Sec.3097,Civ.C.).' . / .-. , . .- . � � ADDRE55 fIoOZS- �OEj'//`I� _W�P . __..__._ �....�� .:. . . .... .. tender'z Name . � cin_ JhiD vSTR h�.No. 33(0— l21 - _ . . ..__ . Lender's Address S7ATE (� L�C. �-Z a I cenify ihot I have read fhis appltcation and sra�e�hor ihe uceNse No. 3�j S.�(oU � Cinss . ..-.. ...._.._. ...._..� .._ . . .._. . . . .. . . . _ .__ . obove informotion is corretl.I agree to comply with all County ' ordinonces and Srate laws relating 10 building construction, ' " � and hereby authorize representaiives af this Counly lo enter- � - - ��� - � -�- -� ���--- �� '�� �-�--�'- "-�- � �� � - � . upon�he obove-mentioned property for insped�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ___ _ /0-/Ei`8 /. . . . � - - Siqnafure o Applicon�or Agent � Date .. . . -. . � . ........ . . .. ..�. .- .. . ._... . . i - .-. , �--�-=; --i,- --�----I --�----+ . _ . i � ; i , `, - . " i ; ; ' ' , . _ . . , j � • . i � ', � , ^ �� I � � ' � -� I Z i�� ' � N • � � � . � . I - . '9 ' . i, ' , i , T('� � � - �1 - ` �' , . ._ � �. � A � ' . .. �. , . i �� �. N � _ .-. _ . . , ,� � t ' Q . i; 1,� i � , . , .,. , i , `'. Y. . N _ � � I � i i _. _ . 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