HomeMy WebLinkAbout1370 VALLEY VISTA (30) WORKERS'COMPENSATION DECIARA710N qppUCATION FOR PERMIT
1 hareby aff7m thot I have a certifimte of conseM to self
insure,or a cenifico�e of Wwkers'Compensotion Insurance, ���� - ��ATING - VEAITILATING - AIR CONDITIONING
or a cerlified c py thereof(S c.3800,La .C.) , ,,,, „ ,,,,,,
F ! n-v� CE-818�REV.t018i)
��Y t'�b. o pcny C_G{ �
Cartified copy is hereby f�rn�shed. COUNTY OF LOSANGELES BUILOlNG ANDSAFETY
Certified copy is filed witb�he co y building inspeo- FOR APPLICANT TO PILL IN -� BU�L��NG / �S �
�on e ent. `r'� ADDRFSS l 7U �� �s�f
5 (PRINT OR TYPE ONLY)
DOt@ Applicant NO, TYVE OF APPl1ANCE OR EqU1PMENT FEE IOCAIItY
� CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESt
i 9� COMPENSATION INSURANCE CRO55 5t.
�hts saetion nMt1 nof M complaiod 81ho work In�olv�d br ABSORPTiON uN�T,Btu OISTRIR NO. VGOCESSED BV
tha parmit is for on�hundrod do4fan(SI00)or IQss.) AiR NANDUNG UNiT,CPM j/� �
�certify thpt in the performante of ihe wrnk for which Ihis ��J M„ (^,
permii is issued,I shoft nor employ ony person in any manner ����
so as fo become subject to fhe Workers'Compensarion taws. 6OItER,BTII APPRpYALS �ATE INSi[C�OR'S SIGNATURE
Date npP�;�p�r COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, affer moking this Certifitate of VENTILATION SYSTEM FINAI
Exemption, you should become su6jecf to fhe Wrnkers' �
Compensotion provisions of the Lobor Code,yoo mual forth- � EVAVORATIVE fOOLER VALiBATION
with comp4y with svch provisions a this permi�shall be
deemed revoked. FURNACF: FAU—GRAVITY �
LICENSED CONTRACTORS DECLARATION FLOOR 8TU �
I here6y affirm tFqt l am licenxd under provision5 af Cfiapfer 9 SUSPENDED UNIT_
HEATER:
(commencing with Sectian 7D00)of Div�sion 3 of the Business - `ti'A«
and Professions Code,und my license is in full fwce a effect. } �
license Numb � tic Class ��v . . _. .. _......- - 0.
r e S d � °�
Contracfor � pa}e 1O O� O �
❑ 1 om exemp�under Sec. � �
Plan check fee �
8.8P.C.for this renson n.
PERMIT ISSUING FEE i �C�
Dote:
TOFAL FEE � z
Sigrwlure "�F f �
OWNER-BUILDER DECLARATION PLP.N CHECK APPIIGANT . z �
I hereby affirm thot I am ezempt from ihe Confractor's license � �♦ • • e n.. �
Law for fhe followinq reoson (Section 7031.5, Business and NAME
Professions Code}: I � + 4^.� �
❑ I, as ow�er of the properfy, or my employees with ADDRE55 ` " "
wages os their sole compensation,will do Ihe work and C17Y TEL.NO. ¢ ` ' ' '" ' �`
the sirudure Is not in�ended or offered for sale(Seciion
7044,Basiness and Professions Code�.
OWNER k� G`"� —"r�
❑ I,as owner of ihe property,am exdusively mntracting
wifh licensed cvnt�aciors to construct ihe projed(Seo- �`�� 3 D �
tion 7044,B❑siness ond Wofessions Code�. Aoorte
CONSTRUCTION IENDING AGENCY CITY �G�� iEL NO. -
I hereby affirm tbat there is o construtlion lending oqency for �
the performonce of the work fo�which this permit is issued CONTRACIOR �� �
(Sec.3097,Liv.C.),
ADDRE55 L(j 4
Lendar's Name
OTY TEL.NO. g�Z"y yU
lender's Address
STATE 7 7� IIC.
I certify Ihat i have reod this application and state that the ���N�pp, �[/7{/ � Cta55 ��U
above information is cared.I agree to comply wi�h all County
ardinance iote laws relating ta 6uilding consVuUion,
on reby authorixe representatives of this County t enter
u ov ned property for' pe ion rposes. SEE RFVERSE FOR EXPLANATORY LANGUAGE
�`�' l
� Siqnorure of Appticant or Agenr o�e ��'�� "' �� '' '
�
+ o '
v �
d� `� � ° c� c
� � ..�.u L ��m � C C p u j ,
�n C '—y � � rW h y C C t. ? 6'� p,� i �
t '� - o � � . c o N y ❑ �
d N . 4. "O O fl�
N �y� m o s �o� � o? � v �o �.�m y � ?s � o o �
o = ._ o in 0 rn a d�n a�.t ° m�"T� c U fl-c ci x ` c � m .
p O C� Ey O= Q C a.n 0 N y ��+" �y� �'� V O v �C V p � u .
c w C
.A Q Q � � rn� E N n a y`� p D� o� o �Q a� p �. p 6— �
0 `m�, " o a a ° E m a o�.°c �v V c � �� ° ° `r c ° � � � I
s � o N m no c a � m � ° � � o i-m n- d C „�'o 0
-t- '�a w:.'- s'� � � 'y :�- m � �, c Q c r .c �,-o � o 0 0 �� o; c
04C oo �E. '^ � oP o= c' mE c ° �a°' N= o°n � aoa ° � �° � �
� �°a�� 4 0 ° ��.°c o y'c � � °c a o �L '"� d° p� c m o a m � �
>
a 'x �' � � � v �u� x �� ° svc c o� �vs i u a� �-° °'�"' j .L .
G� °' i i° ` a N a3 0 � °'c w c ° o ��v a= o c � c ; � 3� a o
W � ° c o '6 ° ., m v °o ° . �v E o �' "' � a- 3 u 'n � � o
� c o Q o `,`u� um, �,>L �=�d c� c � 3 n=' "' 3 E w` m � N yt X `j c
� - �,'No �, � � �i]o a.a � �, � .°� o- O =� °svc�Op � °' °� � 3 I
tfl L.c a� _ � �= u o�d .�i.i ° �m N �. � o �'�v ' �' o �� `c�.o E �S a O
p� o E '" ' '" -+ o y � 'u�i o �: c� Ev m.ta-- [] D�n �� V � �
Z � 3 C d� O L o O Q D !-O�-'1 �p �y Y v O 0>o � N Q; �L ` � r
� � C 0.� T _
.o 0 6 N '- �„s v c V s'^ " o� '" y O t � c E o c
� '- '" d a'" ° ° c in�o s vy � ?
d c � � � �` m o w ° o� o-°
� � � W` p O.£V� .
L � m
� �
1
j`I
ti
1
w
O
Z
N
�
W
N
z
►
I
t
- Y{
0
�.
N
�
. tJ
Yi
� N
. Z
' 6
1
, ''� •. . �� �
,. • � ., 'Y J���
��...�..
�,.�'�'��--
