HomeMy WebLinkAbout0303A 3716A (4) WORKERS'COMPENSATIONDECLARATION APPLlCATION FOR PERMIT �
I hereby affirm that I have o certificale of consent lo self
insure,or a cer�ificate af Workers'Compensation Insurance, ���� HEATING - VENTILATING • AIR CONDITIONING
or a certified copy ihereof(Sec.3800J l�bbC�)^M�, CE-81B(REV.IOiB�)
Policy No��Company� �
� Certified copy is hereby furnish . ���� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with tha county building inspec- I, FQR APPLICANT TO FILL IN qooaes�5 `3 � 1a.�j.+�sf% �� /L �
fion deporfinent � rL.�,.,9 L.Za�7� �PRWT OR TYPE ONLY) �
�ir8�r(F.�r
Date�Applitant LOCALI7V �,��i �i� �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 57.
(Th2s sxtlon nood no1 bo complofod H!ho work involrod 6y AB�RMION UNIT,BTU p157RICT NO, PROCESSE�BY
tho parmif is for one hundred dolfors(5100)or loss.) �
I cerfify that in the performance of the work for which}his AIR HANDLING UNIT,CFM �
permit is issued,I shall not employ any person in any manner BOIIER,BTU Ub0 �� (��
so os to become subjed�o the Wwkers'Compensation Laws. ( APGROVALS �ATE I SPECTOR'S SIGNATURE
I�'1 S OC�U 4C� CJO ROUGH �JZSIJQ� �
Dote 4pplicant COMPREaSOR,6TU �
F'�TICE TO APPL�CANT: If, after moking ihis Cerfificate of � VENiIIATiON5Y5TEM n,t_ +�v FINAL ��` e•
` nption, you should become subjec! lo ihe Warkers 4'T
'`�„�npenSpfiOn prOvisions of Ihe lobor Code,you must forth- EVAPORAT�vE COO�ER VALIDATION
wi�h eomply with sueb provisions or �his permit shall 6e
deemedrevoked. FURNACE: PAU_GRAVITV
UCENSED CONTRACTORS DECLARATION F�OOR aiU
I hereby offirm thai I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
�(commencing with$ection 7000)of Dirision 3 of the Business ' WAu
and Rofessions Code,pnd my litense is in full force and effecr. '`'�1 3 Q 3 A Y
r¢, a,.,•i e r5 �� b (70 �
a
License Number�� ����Lic Class �d " � � � �2� V
T., Qv}1e s lb8 Uo � I •2440t� p
ContraclwT,Gl�����_�ate '�Z'�� -
❑ F
9�3 OC� 9.Q�,�
I am exempr under Sec. p�on check fee �p a(y ••z t` H
6.8P.C.for this reawn 0%,.l p-8 7 Z
PERMIT ISSUfNG FEE S (e� 5p
Dale:
Signature TOTAt FES
OWNER-BUIIDER DFCLARATION PiAN CHE�K APvuUNT SOp•S
�hereby affirm that�om exempt from the Controctor's License ,
Law for ihe following reason(Section 7037.5, 6usiness and NAME �hh?� �� ��
Professions Code):
' ADDRE55 L� �
{ I, as owner of the property, or my employees with ' {7+` ��'�
�l_l wages as their sole compensalion,will do�he work and- �
Ihe slruct�re is not intended or affered for sale(Section CITY �-t�� TEL.NO.Z��.� �,'�.
7044,Business and Professions Code).
OWNER �3 7 1:6 H
� ❑ I,as owner of 1he property,am exdusively contracfing �7 .�d �
wifh licansed conirnctors fo conshucf the project(Sec- DDRE55 G�lipD � �• ���� �� •+ � •8
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY � �TEl NO.
.1 hereby offirm thot there is a constructian lending agency far � � � ♦�� Q
the erformonce o{Ihe work for whi[h ihi5 ermil is issued \ � ° e����C
P P CONTRACTOR ��e` �eC_hQ--�.0 �
(Sec.3097.Civ.C.). 1 �.%4�8 7
ADDRE55\ \ � `�� �1,. C ,e .^�1 L,
Lender's Nome "�
� .
lender's Address
� OT DC`� U\\ ly��TEL.NO. ��O"'3�I� � � �
STATE '] LIC. - ,
I certify that I have read ihis opplication and state�ha�the LICENSE NO. 'l� l� S Z Cu�.SS e -�� �
above information is correct.I agree to comply wilh all Co�nty .
ordinances and State laws relaling lo boildiqg consrruction,
and hereby authorize represenlotives of Ihis Coanty to enter
on th above-mentio proper far inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� . di-2�€--�'7
Signawre of Appli �or nt Date �
t y� N �n C ._'V "V . `�� O O L l7 O � � L�.a. Q .,_.,I _
� � V H L � .'C. , � ' O a� D , 7 C �� b V O �..�^. C
`� O 3 O m i^ 0 Q�a W y O C �e � W p� �L d a V 2� � . •
� S. �p� � t L +i O L 1 p N �j `y_C �t
0�' C 7
� c ^-o c o �cb o m '' m o� 'c-Q a �. �� .t o o a
Z U � O ; C,�> � �n a G i�� � y~ W t E-C O C N x : 0� � O �
O mm oovo £ m � ° " e o � � 3 � - " o °' N.o3L "c
Q � � °_a��4 a o c� o-�.°c -°.°a o� o �o a o 0 o i� L� u
pt E c � E -- s'� m ° ` �'aU � o am m " � o c—
0 0 � � o� � > r d 3 v o f_ ; ° ° � T o c o 0
V a� Q u' o �E � d.wc-� � a� F 'o °_. ��s v� a Qo �= o `o
u'i E ° m o o� `i� � o- o-` �= o ' a o �,a a� " ' ;
OG x �t' � °.c'"V � y c a � Q v a o.-�,�', o d c�z a o o a� ° p � c
iy a: av � a� �t� axi �°o m�a o -� °�= � r o� � � o m ,n � I
p � � 0.3 � '" � �' m c � o a:° o'� °�o ° a"i'� o C a°��
o w � c ai v o N . � � >v 3 �
� — pO �� „ � ��sx $c o � aaavv-°L > aNNv° ii�� -° �
G'J N �' O U��. C �.� C N� Y y O� O [ C N C
� �=r' .� � c � e �1 o a d d a v F, o � � . � � c 3 E • � � �
� u= w �-a p a c � c 3 ' Q� n 3 a Q ,u j 3-., �
w � ° �E � • � �o � m — : o � � ° o.� o � E �- � o h o a
Z� E a � >,G•- -+ o °' >">o - ' �v � a,�ca y u v � °
,;, 3� a o o t�o m o '�0 8 °'°' �� � o °i � "v c v u' a y
O :�T� N � a��u�a m,a o`•'_.' ?o �,�sv ?-Q� � co �� a° °' a � �
� y a � a.n o o„= „'• o� � � � -� c � c'O �u � °u �, £ �tt o 3
- L � j �,� j � C V N �"1 C 0 d N��L O G E 3 O O � p � N s � CD � O
O y . �O O S �Q � 3 . O G
-_ � m d O �T�U cn t� 4'O
�
H
W
� -
i
Z '
y ,. ..
� , � i
d 4
� I {
� .
I ,
, '
•} � - i
i. " .
' ..... �
J �
' N � �
� r,
z � `
� : o � �
_ � ;
.` � �' J
N � J
Z
� 1
� vl �
r, v�
1 �