HomeMy WebLinkAbout0303A 3716A 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
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