HomeMy WebLinkAbout1381A (7) WORKERS'COMPENSATIONDECLARATION AppLICATION �FOR PERMIT - �
1 hereby�offi+m thar I hove a cerrificora of consem ro self
insora,or a cerrfcote of Workers'Compenso�ion Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certifi copy thereof���$$$ec.3800, b.C.) , 76A36aC .
/� � �� �CE•BIB(REV:10/81) ' � , -
O�Y Po^ .. _. � . .. ....
Certified copy is hereby furnlshed. COUNTY OF LOS ANGELES _ BUILDING AND SAFETY.
� Certified copy is filed with�he counry building inspec- FOR APPLICANT TO FILL IN BUR�iNG � C7�
f� n deparfine 1. �� ADDRESS
�°�'1��f (PRINT OR ttGE ONLY)
Date � Y APPIImM . IOCALITY
NO. TYPE OF ACPLIANCE OR FQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 ST. �-D /I
(Thi�sectlon nsed nof he complafed if the work Involved by ABSORPTION UNIT,8TU DIStR��I NO. VROCESSED BY
the parmlt le for one h�ndred dollars(SI00)or lets.) pIR HANDLING UNIT,CFM � �D � `
1 tertify,thaf in fhe performante of the work for which fhis � � O '(� e.
permit is issued,�shall not employ any person in any manner gORER,BTU —
so as to bemme subjecllo the Workere'Compensalion Laws. nPvaovais onte INSPFCfOR'S SWNATURE
. � / COMPRESSOR,BTU /U ROUGH �p� U---��^
;�'•� Dafe APPIicaM �
NOTICE TO APPLICANT: If, offe� moking this CertiFicate of VENTRATiON SVSTEM FiNnL j�-�t'�� e�—
� Exemp�ion, you should bemme�subjeU fo the Workeri
-}� -�Campenso�ion provisions of the labor Code,you must forth• EVqppRA7NE COOLER VALIDATION
� with comply with suth provisions or this permit sholl be
dBemed revoked. � FURNACE: FAU_G AV TY— D .I
IICENSED CONTRACTORS DECIARATION FLOOR BTU v
I hereby offirm Ihat I am licensed under provi9ons of Chaprer 9- SUSPENDED UNIT_
�(commencing with Seclion 7000)of Division 3 0(ihe B�siness HEATER: WA��
ond Professions Code,and my license is in full force a�d effed, r - �Z v
'/ /'
•license Number�v` � Lic.CIos4-� W ,
/ �13?lA �
� ContraU � ofe//�� - � �j• i • • •`a �
❑ I am exempt under Sec. .. . . . v
W
Plcn check fee I • �5 a 2 5 ,°'n
B.BP.C.ior this reason'
- PERMIT ISSUING FEE S O � r x �
- Dafe: •^ •.�'J.G J c�
TOTAL FEE
Signot�re 3 0 9,0 7—8 8
� OWNER-BUIIDFR DECLARATION MAN CHECK AdPUCANT . � -
I hereby affirm that I om exemp�from the Contractor's litense ,
Law for ihe following reoson(Section 7031.5, Business and NAME
�Professions Coda): � '
� ❑ I, as�owner of fhe property, or my employees wilh ADDRE55 � � � "
� wages as Iheir sole compensotion,will do the work and '
the strocture is not iniended or oifered for sale�Setlion CiTv TEi.NO.
7044,B�siness ond Professions Code).
OWNER
❑ I,as owner of Ihe property,am excl�sively conlraUing �
with licensed coNractors 10 conshod 1he projetl(Sea AD�RE55 /�
tion 7044,Business and Professions Code�.
CONSTRUCTION IENDING AGENCY CITY Q f't.` TE NO. �- -
I hereby aflirm that there is a constr�ction lending agency for
ihe performance of the work for which this permit is issoed CONiQnCiOR i - , �
(Sec 3097,Civ.C.). . .- ... . . . .
ADDRE55 � G . . . . . � " � . ..
Lender's Name �
CITY TEL NO. � r( (�J . . . . . . . . . . . .
Lender i Add�ess ��
STATE LIC.
I tertify that I have read ihis opplicotion and state tha�the ❑CENSE NO. � �C1k55 - � -- - - � � - � �
above infarma�ion is correct.I agree to comply with all CouMy
ordinonces and Sfate laws reloting to building cons}ruction, , ,
and hereby authorize representatives of thls Caunty to enier � � � � ����� � � � � ��� ��� � �
upo e ob re-ment:�ned roperty i r inspedion purpos� SEE REVERSE FOR EXPLANATORY LANGUAGE _
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