HomeMy WebLinkAbout1370 VALLEY VISTA (97) 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
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