HomeMy WebLinkAbout1217 PORTO GRANDE (7) WORKERS'C044PENSATIO.'J DECLARATION �
I herr.by o«�m tha�I have a certifica�e o<<0�5����o,��f APPLICATION FOR PERMIT
i�s��e,or n cerlificale of Vlorkers'Compensafion Insurance, �tA3MC HEATING - VENTILATING - AIR CONDITIONING
or�Q�j ��(�r.d copy hereof(Sr.c.3fl00 Lay,C.)
�{" � ` �CE-AIA�2EV.10/91)
❑oF licy ,��. Company�;�� � .
Ceri�l�ed co�y is hr,�r,by furn�s ed. COUNTY OF LOS ANGELES BUILDING AND SAF TY • /�
�rd coPy is(ilr.d wiih ihe couniy bu�ld�nQQ��spec- fOR APPLICANT TO FILL IN 6UitDinlG
lion deporlmen. ���� /�1(` hDDFE55�
/ / � �P71NT C4 TYPE ONLY)
Da'e �� APPlicant ����C ( � IOCnLIiY '
NO. TYC?CF AC7�IA1�'CE CR ECU�P'"ENT FEE
CERTIFICATE OF EXEfAPTION FR01,1 VlORKERS' n;EacEST �T" ,/,�`�/�� p
COMPENSATION IhSURANCE CROSS 5T. /�' Tc�.��A y
(This sacfion nood noT ba compl�bd 11}ha work Involved by /+nSCa:nCN U'.iT,BrU o�si+u r+u PPp:E15[D BV
Ihe permil Is for one hundrad dollars(5100)or lest.)
I terliiy thof in Ihe performonce of tFC work(or which Ihis h�R HA�DLItiG L'NIT,CF!.1 `�
pnrmit is issued,I sholl not rmploy ony person in any monner
� .�.P��
so os lo become subject�o Ihe 1Yorkers'Compensation Laws. BO'LER,6iU PGP40VA15 oare IYSP(CICP'S 5'GY4TU-F
Da1e � Applicanl CO:'F:ESSOR,BTI,I_,��.ldo 3 g� O a ROUGH �
NOTICE TO AFPIICANT: If, oi�cr mnk�ng ihis CerGiico'c of VFNTRATiCnl5V5iF'd FIN1L a/
E�emp�ion, you should becomc subjec� to thc lVorkcrs' �/
Compensclion provisions ai�hr.Lnbor Code,you musl forth- EVnvOqATIV'COCLfR VALIDATION �/
witn compiy with sucn provisions er this permit sholl be .
�eemedrevoked. FU44ACE: FAV_Go�VITV
LICENSED CONTRACTORS DECLARATION iLOOR BtU 00 p _
I hcreby offfrm iFol I am I�c�nsed�ndrr provisions of Choprr,r 9 ' SUS%ENGED UNiT_
HFAT(R: W���
�(commencing wi�h Seclion 7000)o(Division�el ihe Busine.ss ' �
ond Rofessiens Code,ond my I�cen<e�s in f�il fo�ce and eifect. —�� / � �"
�ca��� C d2Q — a
License N�m6rr Lit.Class_ , V
K
com�a�fo,i� oar�3 i�D—p :�2 3 1,8 A �
u
❑ I am e•ernpl�nd^r cc. �y
Plcn check fee N. . . . .�j a
6.RP.C.for this renson z
��ie:
PERMIi ISSUING FEE S �� I • 1 5�,7,ri
Signarure TOTAL FEE � � � y� 7��
OWhER-�UitDE4 DECLA4ATION PIAN CHfCK AFPIICANT
I here6y a!firm Ihal I am r.zempi Irom the Controcto.'s Lice.nsc , ��.L� —�4
Low for the(ollowing reason(Sec!�on 7031.5,��sin^ss ond NnA'E
Professions Codr.):
❑ I, ns ownrr of ihn n�o���+y, o� my r,m�loyres wi�h ACD�E55
woges os Ih�ir zole compensation,will do the work and �ITY � TEL.NO. '
th�slrutture is nol in!ended nr ailered(cr sale�Sec�ion
7044,Business ond Prefr.ssions Code).
� O'.5'NER �y&fl pUILDERB .
I,as owncr ol 1hc properly,om c:dusively tontrncting .
wi�h I�censed contrnctors�o mnStruU the project'($=o- ^'�'��
lion 70=4,Dusin^ss and Prc!=ssio�s Code). ADCRESS �ONICA.�A
CONSTRUCTION LEkDING AGENCY aTv TCL,n10. '
I hereby a(firm�hai ihere iz a conslruciion lendin�aqency(ar
�he prrformnncn.of the work for which Ihis pr.rmil is issued �CNTaACt�FE1'VAT HEATIN ,
�Sec.3097,C�v.C.J. 86C8 �ERVtC5f1 .
' ncoc�ss E• 1MPERIAL HIGHWAY
Lender's Name SANT� r�p�M� �
CITY TFL.NO. .
lendcr's Addrrss
STnIE UC.
I c^d�fy�hol I hav�read th�s appl�mtion and s+oic�ha�ih? ❑CENSENO ��� C1n55 C� r
above in(ormaiion is correcl.I agree lo comply wiih all County
ardinances ond Stale lows rrintin9 lo buildinq conslruclion,
and hcreby auihorizc representatives of this County io en�cr �
upon thc abc�e• entionrd property fer inspet��on pu�pos . SEE REVERSE FOR EXPLANATDRY LANGUAGE
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