HomeMy WebLinkAbout0032A (6) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
I hereby affnm that I have a ce�tificate oi consent to self
insure,or a certificate of Workers'Compensation Insurance, ���� HEATING - VENTIIATING - AIR CONDITIONING
or o certified copy ihereof($ec.3800,La6.C.) CE_B18(REV.10/81 J
P❑ol�icy No.�}CLO_�OE)l S-ampany �*OT.i1F.N F.Af:T.F. �
Certif�ed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified topy is filed with the county build�ng inspeo- FOR APPLICANT TO PILL IN BUILD�NG
tion department. A�DRE55
(PRINT OR TYPE ONLY)
Date 5-?A-RQ APPlicant�n�h�ad;� j,�r LOCALiiv Dj1�p� $gr Tract�l 42583 II,
NO. TYPE OF APPUANCE OR EOUIPMENi FEE
CERTIFICATE OF EXEMPT�ON FROM WORKERS' CROSSSSt. �t� 1 Job# 825
COMPENSATION INSURANCE 9 �
(This zacfion naod nol b�complefed if The work involred by A�RPTION UNIT,BTII �ISTRICT NO. PPOCESSE�8Y
Iho parmit li ior on�bundrod dollen(�100)or leu.) � �
I certify that in the performance of fhe work for which ihis AIR HANDLING UNIT,CFM �,,/�'`
permit is issued,I shall nof employ any persan in ony manner ' `�0. 0 h e
so w to become subjett to the Workers'Compensotion laws. BOILER,BTU . ApPROVALS DAiE IN57ECTOR'S SIGNA7URE
1 COMPRESSOR,BTU 30�000 1 .00 ROUGH
Dpte oPPlicant - �
�_^TICE TO APPIICANT: If, ofter mokin9 this Certifica�e of VEMIIATION$YSTEM F�NP.L p
iption, you shpuld become subjetl ta ihe Workers'
npensation provisions of fhe labw Code,you must forfh- EVAPORATIVE COOIER YALIDATION
with comply wi�h such provisions or this permir shall 6e
deemad revoked. 1 FURNACE: FAU�&�4VHXe.- l0 00
LICENSED CONTRACTORS DECIARATtON ROOR BtU s��UII
1 hereby affirm thot I am(icensed under provisions of Chapler 9 HEAiER: SUSPENDED 11NIiT
��commancing with Saceion 7000j of Division 3 of ihe 8usiness - N'�� '
and Rofessions Code,and my liceree is in full fwce and affact. � I�I� �d 1�,j5 19 25 }
d
Licensa Number 380543 Lic.Class ['•-'�O r+0�a 2 A V
� �
Contracto�ancho AlT', IT1C.pote 5���--�9 �• • . . •8 �
❑ I am ezempt under Sec. � � •(�� �Jr u�
Plan check fee N
B.&P.C.for this reason
PERMIT ISSUING FEE S 10 0 �' ``'� �'�'� �
Data:
TOTAL FEE 49 75 U Z 2 1 -8 8
Signarure
OWNER-BUILDER DECLARATION PLAN CHEIX APPUCANT
I hereby affirm tho�1 am exempt from ihe Contractor's License � -
Law for the following reason(Setlion 7031.5, Business and NAME
Prafessions Code):
{ � I, as owner of the property, ar my emp�oyees with AWRE55 -
� wages as iheir sofe mmpensntion,witl do the wwk and
the structure is not intended or offered for sole(Seclion CiTY iEl.No.
7044,6�siness and Professions CodeJ. - �
owr�R � �� GROUP
❑ I,as owner of the property,am exclusively controcting �� �
with licensed coMrocfors to mnsiruct the project(Seo- A�DRESS 10 1+ P
lion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY att � h�.No. '
I hereby affirm ihnf there is a consir�ttion lending agenty for � - - �
the performance of Ihe work for which ihis permit is issued CONTRACTOR �CjjQ Aj$� jj�j(,'.
(Sec.3097,Civ.C.).
ADDRE55 1232 W. th Street �
lender's Name
CITY TEL.NO.
Lender's Address -
I cer�ify thaf 1 hove read�his applica�ion and state�hai ihe Sc Ns�r,o. 380543 CLC.455 C-2�
above information is correct.I agree to comply with all Counfy .
ordinances and State laws relating to building construction,
and hereby authaize representa�ives of this Co�nty to enter �
upon t�e a6 ve-ment�on,,e/d��operty fo��nspec�ion pur�p/+oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
�i'� ,��1/llt/J�.l�1 !n"'l0'�t3 X
Signmure of P,pplimnt or Agent Dole
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