HomeMy WebLinkAbout1382A (7) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT .. �
I hereby affhm thot I hove a certificate of consent to self �
insure,or a cerrificoie of Workeri Compensaiion Ins�rance,. HEATING - VENTILATING - AIR CONDITIONING
or a certified co y thereof(Sec.3800 Lab.C.) ♦ 76A36aC •
/�]� CE-818(REV.IOi81 J .
Paolicy Nd!T�- �� mpanyy��� .. .. .
Cer�ified copy is hereby furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY
���I''11�Certified topy is filed with the counry building inspeo FOB APPL�CANT TO FILL IN - BUuoiNG � , � /'
!� io'n de�a�rfin��e�t. /1 (PRINT OR TYPE ONLY) ADDRESS C_t3 � a
Date�l��Applimnt /lcl� IOCAIITY .H ^�1� /
� NO. TVPE OF APPLIANCE OR EQUIPMENT . iEE
�� CERTIFICATE Of EXEPoIPTION FROM WORKERS' - NEAREST "
� � COMPENSATION INSURANCE CROSSST. �" �
(This socllon ni�d not ba tomple}ed it fhe work involvad by AeSoavtiON UNIT,BTU DiSTRICT NO. VRp�E55ED 8Y
the permlf is for one hvndred dollan(5100)or les�.) AIR HANDLING UNIT.CFM 1
I tertify that In the performance af the work for which this , t � �0.\Oi�-Q .
permit is issued;I shall not employ any person in any manner
so as to become subjecl to the Wo�keri Compensalion Laws. bOILER,BTU qppROY0.L5 DATE INSPECiOR'$SIGNATURE —
COMPRESSOR,9TU �y Ov U � ROUGH �o �$--
Date � Applicant
NOTICE TO APPLICANT: If, af�er moking�his Certlfimte of yEMIIATION SVSTEM FINAL 2+�� G'
Exempiion, you should bemme subject to the Workers' ,
Compensafion provisions of Ihe lobor Code,you mo51 for�h- EVAPORATIVE COOLER . VALIDATION
wi�h comply wi�h euth provislans or-this permit shall be �
deemed revoked. - � ' FUaNnCe: Fnu G �Tr � /D
IICENSED CONTRACTORS DECLARATION - fIOOR BiU
I hereby o(firm tha�I am licensed under provislons of Chopter 9 HEATER: SUSPENDED UNiT_
� '(tommendng with Section 7000)of Division 3 oI the Business ' �`'A« �.
ond Professions Code,and my license is in full force and effect. . . ">2 O
, License Number��` Lic.Class� �� � � � G , V
Conirador ate � v� . .. �� 3 8 L� v
❑ I om ezempl under Sec. . .. _ ... . #� � � � �� y
Plan check fee ,n
B.BP.C.for this reasan pERM1T ISSUING FEE S �J I • •5 3.=5 Z.
Date: TOTAL fEE � • ° •��r J`;
Signature �
OWNER-BUILDER DECLARATION MAN CHECK A7MICANT - . O 9�O 7—S H
I hereby affirm that I am ezempt from the Controctor's license �
Law ior the following reoson(Section 7031.5, Business and N/+mtE - - � .
Professions Code�: � �
❑ I, os owner of the property, or my employees with
AD�RE55
oges os their sole compensotion,will do the work and CITV TEL.NO.
Ihe struclure is not intended or ofiered far sale(Section
7044,Business and Profe55ions Code). pVyNER
❑• I,az owner of the property,am exclusively conlrac�ing MAIL /�� �L
with licensed coNroUors to comtroct the projeci(Sea qoDRES� �///� tj�
tion 70E4,B�siness and Professions Code�.
CONSTRUCTION LENDING AGENCY CITY L NO. r`� �
I hereby affirm Ihal�here is a tonshuction lending agencyfor
the performance of Ihe work ior whith fhls permit is issued �pNTRACTOR , �
�Sea 3097.Civ.C.). . . .. . . .
• ADDRE55 � - � - � � � -
Lender's Nome
. CITY . . TEL NO. _�` � . . . .
Lender's Address �/ '7
Y I STATE �`I J�I Ctq55 ,^�
I certif thot I have reod this app icotion and slate that ihe LICENSE NO. - � ---�-- - - ---- �- -- - - � -- -- - --� - ---
above informa�ion is correct.I agree to comply with all Co�nty
ordinonces and Stote laws relo�ing lo building mnstroction, . _ _ _ . . . . .. , ,
ond hereby authorize�rep�eseMatives of this Counly to enter . �
upon t .above- entioqe�d/pfroper�y for inspection urp es. SEE REVERSE FOR EXPLANATORY LANGUAGE '
gna re of Ap,i; nl�gem � r� Dore ' . . _ . . .. . , ... ._ _..... . . . . . . . .
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