HomeMy WebLinkAbout1370 VALLEY VISTA (64) WORKERS'COMPENSATION DECIARATION AP��'CMT�ON 1'V� P�RIY{�T I
I hereby aff?m �hat I have a certificate of consent lo self
insure,or n tertificate of Workers Compensation Insurpnce,
or o certified copy�hereof(Sec.3800,Cab.C.) ��+3eac - HEATING - VENTIEATING - AIR CONDITIONING
CE-81B(REV.10/81)
�cY�V.O.��mpony�c lrQ./ ._—___
Certifiad copy is hereby fvrnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY �
l
Certified copy is filed with the nty buildi ec- F�R APPLICANT TO FILL IN BUIIDING �
tion epa menf. ADORESS
(PRINT OR TYPE ONLY) � LL F � L Y
�ate h Applimn lOCnliTv r��� ����
' NO. iVPE OF APPLIqNCE OR EQUIPMENT fEE
i � ERTIFlCATE OF ExEMpTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS Si.
ABSORPTION UNIT,8TU
hi�a�clion nwd not Iw comp4f�d{f fho work Involvad by o�SrRicr rno, v¢pcessfo ev
1ho parmli Is loi ono hundrod dollan(5100}or ivu.) �� � �
AIR HANDLING UNIT,CFM
I certify that in the perfarmance of the work for which this
permit is issued,f shall no�employ any person in any monner
so as fo 6etame subjeU to�he Workers'Compensaiion laws. BOIIER,BN APPROYAR oaie INSVEQOR'SSIGNATUfiE
COMPRESSOR,BTU �
�ate APPIi<ant ROUGH S �
NOTICE TO APPLICANT: If, after making this Certifimte of VENTiIATioN SYSiEM FINAi t
Exemption, you sbould become s�6ject to �he Wwkers' � �
Compensntion provisions of the tabor Code,yw�mps�forth- EVAPORATIVE COOLER - VALIDATION
with [omply with such provis�ons or �his parmi� shall be
deemed revoked. FURNACE: FAU_GRAVI7Y
IICENSED CONTRACiORS DECLARATION FtoOR B7U
I hereby affirm that I am Iltensed under provisions oi Chapter 9 h1EATER� SUSPENDEd UNIT_
(tommencing with Section 70qp)of Oivisian 3 of Ihe Business w++«
and Protessions Code,and my license is in full force and effect. � �
Licanse N�mber �� Lic Ciass " �Q Q. -
I O�.� S � � �
co�„o«« ��� �o,e � �
❑ I am exempt unde.Sec. �Z.. �� �
Plan check fee V �
B.SP.C.for ihis reason
OW..
Date:
PERMIT ISSUING PEE S a C �
TOTAL FEE z i
Signalure �
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT ��%��' I ;'.
I hereby a{firm that t om exempt from ihe Contracto�s License � #• • c x .�
law for ihe following reoson(Section 7031.5, Business and NAME �
P.ofessionsEode): ' `a L",c'_Y'
❑ I, as owner of �he properfy, or my employees with A�RESS
wages as their sole campensat�on,will do�he work and �a ��^ ;. -_
the struciure is no�iniended or offered for sole(Sedion ��T� TEL NO. -� ��
7044,Business and Professions Code�. � c
OWNER �µ� �-—G�
❑ 1,as owner of the proparty,am ezdusively contrac�ing
with licensed controctars to construc�the projecr(Sec- ���
lion 70E4,Business and Professions Code). /+�okE55 / r,s
CONSiRUCTION LENDWG AGENCY CITY TEL.NO.
I hereby affirm thar there is a constroction lending agency for �
�he performonca of the wo�k for which�his permit is issved CONTRnCTOR
(Sec.3047,Civ.C.}. I
A�DRE55
lender's Name �
Lender's Address CITY � � T�_�.�p, �_/� vT
7 7��
STATE n CL4/�
I cerlify that I hove read tbis applimtion ond s�ate thot the lICENSE NO. V fS
obove information is correct.�agree to comply with all Counly
ordinan rt9'State laws relaling to building ro lruction,
au on �ces�ntatires of fhi u to eMer
e mrSt�e3 properry f i ' oses. SEE REYERSE FOR EXPLANATORY LANGUAGE
t
� Signalure of Applicon�o�Agenr pore i
I
�
\ �
t b
0
G `q, � C? �n p
d� Q 0-�
L O a ,.C,.'O U C C O O N
;,i +T-,j C rn L >`C4 V O-� _
c u c
,� a_ad c. �o �,a"° � L N� Y ° o �
m m ,-. � � m a,
�}'Y N O � p C Y U C'y0 C.P O.O1 � X i y1 � -G G
� ,r,�n �` o.�� °d�+.m..�c ° s ° o a s o� n °� J o� �' °±
- s ._ o N O.rn o. �. � m a+ °� �- m .c � . � Q E �tJ c ro_ '
�o � E omc �cv_.°''" � � o c3 p %oo-°'Q ' � +°r
o e^� r � m d o,'O c yPJ G o „V,�,.'�D p C 6-6: D O N �� o C O t
G�
c c � > E �`E ° 'n � .O .pv � � E 3 m d n. ro � �Q,°m u � c
l,j O �' Y D tl'O E G O O ,n .- d ✓� Q C S '�'-4 C�U N d� p � O
O � �� R N Ol �� � `� ..- N y„:,`- � Y 6) �:. p.O� Q'0 0.p" Q 6i � 07
"`•. s � O � a Y� N Ol G N � N OJ
-F =� E e °' c9 � �- E c� � a.c m � " � y o-o c � c � N
� � o � y o ��o-� �''' o c av� o°,s �' >° o-o No at� � ..s
4 y q � .. .. o o-- E � °°, c y v o 3 o m �, �� E• � p, o
yp' �- o°-�v�. X ° °o s �,c �,°�-o ot ° � d �o �, o E �
� rn m v � s m n, � D c a> d � � o. � � �-+ o u� � U m
� � �o2a-� u.3 o '"- E o p ° � N� E � e+ � ; E °,sm N�d� n: o- • 6 O
�G N p t,� ✓� a'O � a �u X .'i G W O G �i Q� d ' 6 � C�- O G pj1 �
g p O O p �`.C N C.l O � O.n' ,r, ✓ j'� O G+ � M� � " �i O „ 1� 0'V O CD
'N �Y C y� C T,p p.� p. C ��fa N.,�0 v� „�� d�� � LGT t`- r O V S
� p L m .- �" �." d O �L'V O 9 j"x � �'� L C� O �� � U1 O� � •-
� � M .'� N "� 0 d D `�' 'G 4 'd p C C O N�-.
OC ° E T°' c� � N o T�v+ .- Lr::+ � v o,�� .-
Z E�v a o�'c o$o m� ° ��' s � � L o � E o
c o � �V s,n - o... � �"0 3 �
� wp c N �•a�t o o � �,.,o o t..�
0 9cc�@?E���oo� �9
�
s � � 0� Q � �
� � `
\ f
� `
2
�
O
W �
Z
\
�
O
Z
�
O
Ow-
. Z
�
� /
'is�-/
.'-''' ��