HomeMy WebLinkAbout1370 VALLEY VISTA (96) 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
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