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HomeMy WebLinkAbout03_17_1983 - 2016 PEACEFUL HILLS RD � �v b �(G�cp � WORKERS'COMPENSATIONDECLARATIDN p��. 5� . qppI,ICATION FOR PERMIT insurebor ofcertif cata of Worken�Compensot on Insurancelf 11`- 3Z5�� or a certified copy�hereof(Sec.3800,�ob.C.) �enanac : � �HEATING - VENTILATING - AIR CONDITIONING P'Zb 6l� 7�,A� . CE-B18(REV.IO/811 . POolicy No. Company - .. .. ._. . .... . .. Gertified copy�s hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ertified topy is filed with rhe wunty building inspeo- FOR APPLICANT TO Flll IN ADDRE55 �l� � n 1 I IS ►t� hon dep6rfinent /1 n (PRINT OR TYPE ONLY) Dafe -�'I�-a� APplicant +'.H'�.r�y�^"` �. LOCALItY �"0. NO. TYff OF APPIIANCE OR EQIIIPMENT . FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST � � COMPENSATION INSURANCE . CROS55T. ,(Thb s�c}ton na�d not be tomplated i(tha work fnrolved by . ABSORPTION UNIi,BTU DISIRIR NO. PROCESSED BY tha parmlf fs Ior one hondred dollars(S1D0)or less.) 9 I certify,lhat in 1he performanca of the wak for which this P.IR HANDLING UNIT,fFM o( peimil is issoed,I shall not employ any person in any manner - BOILER,BTU - - - 'so as ro bemme subject to the Workers'Compensa�ion laws.. n aooapvni5 oaT[ INSPECTOR'S SIGNATURE . � - -� � . COMPRESSOR,BTU �OIW� � � ROUGH Date Applicanl �ICE TO APPLICANT: If, afrer making rhis Cer�ificare of VEN11L4110N SYSTEM fINAt nption, you should become subject 10 �he Workers' � . (.ompensation provisions o(the Labor Code,you must forth- � EyAPORATIVE COOLER VALIDATION � with comply with such provisions or.�his�permit sha�l be , deemed revoked. � � � FuaNnCE: FA GenvITY ' - -- �� _ LICENSEDCONTRACTORSDECIARATION � FiOoa - eiuj�O�f?OC'� � � I hereby affirm that I om licensed under provisions of Chopter 9 HEA7ER: SUSPENDED UNIt_ � � '(commencing with Section 7000)oi Division 3 of�he Business WA« � and Professions Code,and my license i:in full force and effetL � a L1 �_ l5 3 � o Ucense Number� 1�z-�� lic.Closs Z� - ►. V co��,o«o� 1r.�ine�lles-F— Dore3—I^I� zb'�',x2A � O r- ❑ V I am exempt vnder Sec. �',• • • • •a w Plan check fee �- B.SP.C.for this reason� � - - PERMI7 ISSUING FEE S Id'S I • •5 fi 7 5 � � Date: S�gnotore TOTAL FEE � . . .5 6 7 5� � OWNER-BUILDER DKIARATION PLAN GHECK APPLICaNT I hereby a(firm thot I am eaempt irom ihe Contractor's License � , ��2 3—$3 law for the following reason(Section 7031.5, Business and NAn4e . . - � . Professions Code): . � � .... �. _ _.. __. _. . . . __. ADDRE55 _ - ___ . _ _. . _. _ ._ _ . .... __ . . _ ___ _ _._. _ . . -_. - . - I, as owner of�the property, or my emplayees wi�h ' � wages as their sole compensalion,will do fhe work and �IN � � TEI.NO. � Ihe structure is not imended or offered for sale(Section 7044,Bosiness and Professions CodeJ. , � --- - ---- � � OWNER � S ❑ I,os owner oi the property,om exdusively conlroUing � " wilh licensed comroctors to conshucl the projett(Sec- �"�'�� � � �- tion 70E4,Business and Professionz Code). � . /+�oeE55 � ��� �' 2�� . CONSTRUCTION LENDING AGENCY - �- ary - ' � � ---� ict.�No.�P{ ..�) (� I hereby effirm tha�there is a constr�ction lending agency for the performance of the wa�k for which�his permit is ISSVOd - COMRACTOR 'ry� ���- � -� $ j� �� , (Sec.3097,Civ.C.). . . � . . . ._. . ..._. . .. . "'... ._ __ _ -. /' ,.. . . � � ADORESS�I � �.Pac�'C�CO ._ "_ . .____ ..__ ,.. . Lender's Name ' � ' lender's Address - .. _ aTr ��181YYt � . tei..No.��{-Z7( . _.... . .. . ... --.- -- .. . - .. . � STATE `f� UC. I certify that I have read this applimtion ond sfole that fhe-.� LI[ENSE NO. -�1 �CU1S5 Z�� - - � ��-� --- �-- � --- -� - � �� � � � obove information is correct.I agree to comply with all Counry ordinances ond Stete laws relafing�o bvilding construclion, � , .,,. , � .. . . .. _ _ . . _...__.._ ___ ... _ ._ _. . . and hereby authorize representatives of this Coonty�o enter � � � - -����� opon the obova-mentioned property(or inspection porposea SEE REVERSE FOR EXPLANATORY LANGUAGE �Q-l�Qc9 l.m.sn 3-('1-� _ Signafvr of Applicanr or Agenl - Date .. . . .�. . ...... .. . -. . . .... . ... . . i .. .._ __.. . ;-__ - -- , --- . _�. . ., . � � _ , . .- ; ; � , � � �✓ . � . i .. . . . ' - . ; ' ` . , . _ � :� . , � ; , t ; �; � ', . . '� ; � _ � - � - , ,. ♦ a '. � • . 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