HomeMy WebLinkAbout1466A (8)- -WORKERS' COMPENSATION DECLARATION
APPLILATI
1 hereby affirm that I have a certificate of consent to self
inssife or a certificate of Workers' Compensation Insurance, --
-. -- .: HEATING • VENTIL
'
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s9ed copy therreeo Sec 3800, Lob. C.)
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B (REV 10/81) .. ...-
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pony
'Polity No.rt
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Certified copy Is hereby furnished. - >- �� -"
COUNTY OF LOS ANGELES ,
If�'3J
Certified copy Is filed with
lion gar-m
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FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
*4nsp'
Date" v Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT " F
CERTIFICATE OF EXEMPTIO
COMPENSATION INSURANCE
- -
'Thisrection need net be completed If the work involved by
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_- 'the permit is for one hundred dollars (5100) or.less.J
-
I certify that in the performance of the work. for .which this ..„
AIR HANDLING UNIT, CFM
permit is issued, I1 shall not employ any person in any manner
'.
so as to become subject to the Workers' Compensotion Laws.
BOILER, BTU
Date APPlitdnt
COMPRESSOR, BTU sJ l
NOTICE TO APPLICANT: If, after making. this Certificate of
VENTILATION SYSTEM.
Exemption, you should' become subject to the Workers'_..
# • e • • • 8
Compensation provisions of the Labor Code, you -must forth-
EVAPORATIVE COOLER -
-- with comply with Such provisions or this permit shall be
-
deemed revoked.- '- �- - • ., -
FURNACE: FAU —GRAVITY
LICENCONTRACTORS
FLOOR BTU -
'- 1 here affirm haft II: am icensed under provisions of Chapter 9
' by W P
HEA SUSPENDED UNIT_
'(commencingwlh Section 7000) of-0ivisian 3 of the Business
- WALL
and Professlons Code, and my license is in full fore�^�`,and effect.'
MAIL _
License Number' lc. Class �+
sr u Lr
' Contractor pate
- -
El'T am exempt under Sec
IDN FOR PERMIT
ATING • AIR CONDITIONING u
I
BUILDING AND SAFETY
1
BUILDING g //// Cho f.
ADDRESS 1'Y L C.r
LocAUTY
EE sOwn ArA
CROSS 3T.' C"A 6w- S 'L'JJL{ t
DISTRICT NO. PROCESSED BV
APPROVALS DATE INSPECTOR'S SIGNATURE
ROUGH
FINAL
VALIDATION
#4144 .
1.610.00=
e�e1 0,00,
09,08-88
•
'fn
Plan check ee
_
8.8P.C. for thison
O
PERMIT ISSUING FEE >< C]
e:
`i.
TOTAL FEE < C,
Signature
OWNER -BUILDER DECLARATION
RAN CHECK APPLICANT.
...�.�
j
1 License
hereby affirm that I am exempt from the Contractor
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®
$ 1 A 6 5 A
Law for the following reason (Section 7031.5, Business and
Professions Code): - . I `i - "
NAME
❑ 1, os owner of the property, or 'my employees with -
ADDRESS .�'
- -
# • e • • • 8
wages as -their sole compensation, will do the work and
CITY �—
TEl NO
(A b 2275
the structure is not Intended or offered for sale (Section
.
- -
7044, Business and Professions Code) ' ' `"
- -
OWNER,— t`
� -
_:
e • e 2275r.T
D_
I, as owner of the property, am exclusively contracting
MAIL _
_..�. ...
- with licensed contractors to construct the project (Sec- ADDRE l �- -09.08-88
tion 7044, Business and
1 hereby affirm there IO o LENconDING
AGENCYProfessionsG NC Code).
g agency for � CtTY � � - Ar'> " TEC -NO;-'
the performance of the work for which this permit is issued- - CONTRACTOR-
(Sec. 3097, Civ. C.). -q
ADDRESS .. 8 ..... .. _ . _. '
Lender's Name
... CIN V '- TEL. NO,
Lender's Address - - 1
1 certify that I hove r ad this a [Icarian and state that the ... STATE
1 Y PP LICENSE FID. " f 6- CLASS
above information is rrect. I agree to comply with all County _
- ordi nces and Stat lows relating to building construction,
and reby authad oneallves of this County to enter
" the ob ve-m iperty for in ection urposes. ,.SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applic i er Agent Dore ..... ..: _ .. -
INSPECTOR'bNOTES
NER BllILD
:OW EROECLARA
ATON,
t
`ffr
�� � affl—
Phereb that I am exem p om fhe Contractors
cense ow for-
rLusiness
, ; ,"'_ ?
.. j . y y , / J } }�"y C � - i ._h
Bovn`ijw l"ch
and Professions Code) Any city ct
- rkuires u perm' to construct alter;, imp ave' demoHSh,
,�
--- U --
S� eK repair arty fracture prior"fo f1s I�,cuance .also re
}.,fquir�s tit@ gpplrt for such perM�t ib f fe a signed state-
-
me thgf he ll konsedpuesuant to the provlslons of the
Conir6cfor s.Lkense J,aw fChap4r.A (commencing with
Section 7000), Division, 3 ofthe,B,usiness and prgfes-
of
or Ihaf he is bosis
Athorefrdmandfhe�cion
of Secflon
14 Q pf/on Any _ Gl'sublec
ia9th ,cAn
a hcant�ion..
PP %r a permit subJects ihe'appli_.
-
Y
, .c ntt to a penult ,pf not morer than fwo'hurrdr
�
--�— i.- I
dollars($500),:_yll
.. i °
--.=
I a ss, owner of the property will do the work, and
ns��
r ,
�hoffproperc-
hpplY property
EPwd es out
'who
builds art hot does. such
work himself provided that such improvements are not
intended be offered for sate4f,_h6we0er, the building or
"-
improvement is sold within one year ,of completfort, the
owner-builder will have the burden of proving that he did
notal/dorm prove for the purpose of sale.) r
exclusively
sl
' t ! "" —,
--- j /
-ire rin❑g'with cense r, 'for t oosttoct the piojad
oG
Bustnes#, 01'.1 pfssl4r de the Controc-
tor' iconse haw floes riot to on owner of pioperty
-
ply
whd;builds or Improves thereon, and:wha contrgtfs for
such projeCf; with o controctor(s) licensed pursuant to
,+
lithe �C ador' !i7 Law
fnse
am exempt under Sec
B & P.C. for this reason
(
ate
owner ..
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f
INSPECTOR'S NOTES f ,
T i•7� � `J'�_ L 1