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HomeMy WebLinkAbout1149A J WORKERS'COMPENSATIONDECLARATION ��j �/�ll„�ePPI l�'ATI[11U CAD P�DAAIT �� � I nefeoy u?ilrm ihGi I have G Cerliiicale oi mnseni b self � �/ !���%��a a iaa�ra a avo= : �sa o �seaeaa a ¢¢¢ insure,or o certificote of Workers'Co ensation In urance, Y�� `�"' � jjj3 a,o�Pmf��r/g-��j���� seoo � . r C6A3848(Rc✓ �E) HEA?ING - VENiILATING - AIR CONDITIONING � y Policy N� "P�. � mpany � .Y— _ A � � .. � � � Certified copy is hereby fumi'sh� . � ���vy''�f�✓ COUNTY OP LOS ANGEIES � BUILDING AND SAFETY" / . !/!"/ I - � ��,f Certified copy is filed with the county b�il in is c- FOR APPLICANT TO FILL IN auaoi oJC f'on�g�py�n�/ (PRINT OR TYPE ONLY) ADD �� ��g/Y�! � p� � 4✓�Applitar� /` IOCAUiv 4 NO. TYPE OF APPLIANCE OR EOUIPMENT FEE CERTIFICATE OF EXEMPTI FROM WORKERS' . NEAREST COMPENSATION WSURANCE CRO55 S7. (This sectlon need not 6e complefed if fhe work involved by ABSORPTION UNIt,8TU oisreicT No. ppp��� akocesseo.gr � �� the permit is for ane bundred dollars(S100J or less.) � I certify that in the pecformance of the�work for which ihis AIR HANDI.ING UNIT,CPM � permit is issued,I shall not employ ony persom in any manner so-as to 6emme subjecf to the Workers'Compensation Laws. gOILER,BTU aaasovnt5 DnrE t• FCToa's sic,Naruee Date Applicanf COMPRESSOR,BTU ROUGH _ r� ���r' NOTICE TO APPLICANT: If, otter making ihis Certificafe of VENTILATIONSYS7FM FINAL �,� .G,� Ezemption, you should become su6ject fo ihe Workers' Compensation provisions of ihe Labor Code,you musi fiorth- EVAPORATIVE COOLER VALIDATION � � wifh comply wiih such provisions or this permit shall be � deemed revoked. FURNACE FAU RA LICENSED CONTRACTORS 6ECLARATION f�00R U � I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_ HEATER� W �� �(commencing with Section 7000)of Division 3 of Ihe Busi ess �, ond Professions Cod d my �cense� �n f�ll force d e n c g4 � license Number� � Lic CI ss , � � ' r — f: �'' CoNratlor � � ❑ . . �(�_- � I am exempt under Sec. �' }^�!,� v+ Plan check fee "` � w e.&P.C.for this reason PERMlT ISSUING FEE$ �:4�-��"�'� � Date: Signatu�e TOTAL FEE OWNER-BUILDER DECLARATION NtAN criECK aPvuCaNr - I hereby affirm that I am exempt from ihe Coniractor's License ► . � � � Law for the following reason (Seciion 7031.5, 8vsiness and Na�vte � . � Professions Code): ❑ I, as owner of the property, or my employees with A�DRESS . wages as Iheir sole compensation,will do the work and CITY TEL NO. � � � � the structure is nof infended or offered for snle(Section J 704d,8usiness and Professions Code). � i � � OWNER � ❑ I,as owner of the property,om exdusively contrading , wiih licensed coniradors fo consiruct the project(Sec- - MAIL - tion 7044,Business and Prnfessions Code). A RESS - CONSTRUCTION LENDING AGENCY i ��. J? ip.Np. - �- - . I hareby affirm that there is a conshuction lending agency for � ' "� . ' � � . - the performance of fhe work for which ihis permit is issued �pNieA • ,- (Sec 3097,Civ.C.). %�� / - � . . . . . � � ' . ADDRE. -. _ .._ . _ Lender's Name fT �a EL.N � Lender's Address � "� . STATE L` ,�, LIC. I certify ihat I have read Ihis opplimtion and state ihat ihe LICENSE No. �-� CiA55 above information is mrrect.I agree to comply with oll County ordinances and State laws relafing lo b�ilding consiruction, and hereby auth riz r pr entatives of this County to eMer � � ��� �-�- _ � � � -- � upo the obov � n�pert for�Po 5 SEE REVERSE FOR EXPLANATORY LANGUAGE JSignW'ure of Applicant or Ageni �ate � � - --_ 3 � .� ; -�' ;� . b:��. , ;� � , ,..� � •� �;�s . , � are � � � >, : � .:. � , , ,_._ ,.. vJi � ` � _ , � ::� . ,. ..�,r', ..�:;� . ,: �.. Y. .. - ; �_ «- ..,,z. , c-_. ' . ... , , � ' � ? 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