HomeMy WebLinkAbout1370 VALLEY VISTA (98) WORKERS'COMVENSATION DECLARATION APPtICAT10N FOR PERMIT �
I hereby pffirm �hat I hove a certifimte of consent to selt
insure,or o�ertifimte of Workers'Compensation Insurance, �
or a certifled copy thereoj .3800 a6.�.) ��+3eac �HEATING - VENTILAT{NG - AIR CONDIFIONING
`H CE-B18(REV.10/81) . ... ��...--�--._ _,._,.,_., ._..._.,_._ ..
a�Y NP�Com n Pl.t(+e/
Cer�ified copy is hereby f�rnished. COUNTY OF LOS ANGELES BUlLDING AND SAFETY �
,.E� Certified copy is filed wilh 1Me counry building inspeo- F�R APPUCANT TO FILL IN BUILDING
tion ent. ADDRE55 � /S
(PRINT OR TYPE ONLY�
Date Applicont ' LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMEN7 iFE
' [��yERTIFI TE OF EXEMPTION FROM WORKERS' NEAREST
�� '1V COMPENSATtON INSURANCE � CRO5557.
(T is tion naad�wf ho complN�d IF the work Invelred by A&SORPTION UNIT,BTU o�sraicr nro ppocE55Ep ghhy
tho pormlf Is for aw hundrod dollorc(il00)o�toss.) q�R NANDLING UNIT,CFM f� �n �
I certify thaf in the performance of the work for whlch�h�s � �`\
permit is issued,1 shall nof amploy any perso�in any manner
so as to become wbject to rhe Wo.kers'Compenaalion laws. BOIIER,BTU APPRpVqLS o�tE IILSPECfOR'S SIGNANRE
Date �lpplimn! COMPRESSOR,BTU ROUGH ,S y �
NOTICE TO APPLICAM: If, offer making fhis Cerfificote of VENTIIATION SYSTEM FINAI LP 1 (�,��
Exemption, you should become eubjecf fo ihe Workers'
Compensofion provisions of fhe Lobor Code,you mus�for�h• EVAPORATNE�OOLER VALIDATION
wilh compiy with such provisions or this permit sholl be
CIEBm2fI revolted. fURNACE: FAU—GRAVITY �
LICENSED CONTRACTORS DECL4RATION fLOOR BtU
I hereby offirm thot 1 om licensed under provisions of Chapter 9 HEA7ER: SUSPENOEO UNIT_ ;
(cammencing wilh SeUion 7000)of Division 3 af tbe Bus�ness ' WA« �
and Rofeuians Code,and my license is in full force ond effetl.
�r �r Q
License Number tic.Cfass ` �� � � � � Q
� K U
Contrador 'U Dote
� f am exempf undr Set. f � � �
Plon check ee
B.BP.C.for this reaeon �1e' PERlVNT ISSUING PEE S �d N �
Signature
TOTAL FEE � �
OWNER-BUILDER DECLARATION RAN CHECK APPLIGUVT
1 hereby affvm thot I am esempl from the Contrpdor's license �
Law for�he following reason(Secrion 7031.5, Business and NAME �
Wofeesions Code�: _
❑ �, as owner of the property, or my employees with ADDRE55 '�.��C�'ri
wages as their sole compensation,will do the work and ��TY TEI.NO. t s 8 4 . -
ihe structure is not intended or offered far sale(Sedion -'
7044,Business and Professions Code). - � F �.
❑ OWNER — 1 . 0✓ � ° �[. /�.:
I,os owner oI�he property,am exc�usively cont�octing v"
with licensed conhoc�ors tv consn�c��he project(Seo- ��� � s o��i ' -
tion 7044,B�siness ond Professions Code). nootteSS � � •
CONSTRUCTION LEN�ING AGENCV �ITy �„ 7EL NO. O L� C—�-�
I hereby atfirm that there is a construction lending agency for ,
the performonca of the work for which ihis permit is issued CONTRACTOR
(Sec 3097,Civ.C.). i✓
ADDRESS � - � �
Lendei s Nome � �/�'�'�
tender i Address ��TY � 'eti'-' QN TE�.NO. t�� 9D i
stnte �7 uc. -7 G j
(certify�ha�(have read�his application and state tbat the LICENSE NO. � (/ � CIASS `C . . .. !
o6ove infarmofion i5 correcf.I ogree to comply with all County - i,
ordinantes ond Stale laws relaling to 6uilding construdion, i,
and h y aurhori representotives of tK C unty to en�er � �
up ��bove- ntioned proparry f� n �dn y�y�(ias. SEE REVERSE FOR EXPLANA70RY LANGUAGE I
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