HomeMy WebLinkAbout1380A WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PERMIT - �
I hereby oflNm ihat I heve a certificate of conseM�o self . �
insure,or a cer�ifimte of Workeri Compensation�nsurance, ,bA3eac :HEATING - VENTILATING - AIR CONDITIONING
or o ceriifi d co y Ihereof et.3800, .C.) � �
/�/7 � CE-818(REV.10/Bl) . .. . .
P❑alicy < < pany � ' . .
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified topy is filed wiih the counry building inspec• � FOR APPLICANT TO FILL IN BU4DiNG 1 //�
tion deparimen �pRW70R TYPE ONLY) ADDRESS � �/ O((� v�r
Do1e ' —I� APPlimnl � tOC/+li # 7 �
NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' nIEARESt '
� COMPENSATION INSURANCE . CROSSST. �
(Th��s�Hion nead nof ba eomplofod if fhe work Involvad by ABSORPTION UNIT,BiU DiS�RiC7 NO. PROCESSfU BV
the permif Is For ona hvndred doi�an(5700)or less.) ' . �D
AIR HANDLING UNIT,CFM �(��
I certi{y tha�in�he performante af the work for which this � \��0.�0 n `'�
_ � permil i5 issued,I shall not employ any person in any manner gOILER,BTU
so os to bemme subject to ihe Workers'COR1PCf1501100 LOwS. AFPROVAlS DATE INSFECTOR'S SIGNATVRE —
Dote � APPlicanl ' � COnnvaE55OR.eT� .� ��- I� �� ROUGH o/l� (r--
NOTICE TO APPUCANT: If, ofler moking this Certificate of - VENTILATION SYSTEM FINAL� jZ/jQ� U--��
� Exemptlon, yov should become sobjeU to the�Workers'
Compensofion provisioni of Ihe Lobor Code,you m�st forih- EVAPORATIVE COOLER - VALIDATION
with tomply with such provisions or this permH shall be ,
deemed revoked. � � � FURNACE: FAU GR TY �
LICENSED CONTRACTORS DECIARATION ROOR BTU ��— /
I hereby affirm that I am licensed under provisions of Chopfer 9 SU57ENDED UNIT_
���commencing wi�h Section 7000)of Divislon 3 of 1he Business HEATER: WA��
and Professions Code,and m license is In full force ond effect. ' � � � �"
� Y /� d- C� Z p
, License Number��nLic.Class`-' � � - � V
CoMractor��/"'+_'✓ /�'�' Do�e //-�� �� J�n A Ot '
tl. . o . .g o
� ❑� I om eaempt under Set. . . w
� Plcn check fee � s .�j,2 5 y
B.BP.C.for this reason� Z
' pe e, PERMIT ISSUING FEE S G� • •;5�.L��
Signawre TOTAL FEE 0 9.0 7—�S
OWNER-BUILDER�ECLARATION PLAN CHECK APttIGAM , .
I hereby atfirm�hat I om exempt irom the Contracfor's licensr. �
law ior the following reoson($ection 7031.5, Business and NAME �
Professions Code):� � -
❑ I, as owner of the property, or my employees wilh ADDRE55
woges os thei�sole mmpensotian,will do the work ond . -
the str�cl�re is not intended or offered for sale�Section Citt iEt.NO.
7044,Bosiness ond Profess�ons Code). . -
OWNER AI
❑ I,as owner ot the property,am eKclusively conlrotting ��� �
-with licensed mnnactors�o ronstrud ihe projec�(Sec- ��� `
lion 7044,Business and Professions Code). ADDaE55 J i/'
�ONSTRUCTION LENDING AGENCY ' air ' . � �� iet:N . �r�QO
I he�eby afiirm that there is a tonstr�ction lending ogency for � ,
- the performance of the work for whith this permit is issoed CONmnQOR .
�Sec.3097,Civ.C.). . . - . . , . . . '
, ADDRE55 � ,�( � - . . _ . � . . .. .
Lender's Name ' -
r
. . CITY . �_ TEL.NO!'73 � _ . . . . � .
Lendei s Address
I tertif thot I have read Ihis o lication and s�ate Ihat ihe STATE ` ' IIC. -
y pp LICENSE NO. `-t CLASS � - - �� -. _ .. . ..
above infvrma�ion is correct.I agree to comply wi�h oll County
ordinonces and Siale laws rela�ing to bvilding construUion, � �
and hereby authorize representatives of this County to enter � - -- � � � ��� " -"�" -- � - -
upon the obove-mentioned prope�ty for inspeUion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE .
� -zr-�
Signature o Applicont or Ageni Do�e . . .. . . . .. .. ....... . ... .. .: . . . ... ... -'�'--'
� - - "" .`. .
- . 1
. y :,
� '�
:� � , .
� � .
, , , .
i '. , . • . ;
, -
• ".. '.- . - � -
b � . ; �f '. '
rn .. ' , . :x
� ,� •�'' ' " .•'�� ' ' , ..
N ..
� . � � ' " . . • •
� . , � . .. , . �
., ' ', _ . ' ; I .
i _ . - -.
� ... �• ';�• . - , . '- � .
� � � � . .. "_ ' .
�� " ' i . . '. ', ' . .
,.
� . , ; :t m .
• , �?i
. • � , ' �
N
� - ' � ` �
'' ' � ' _.. ' . . . O
. - � t N
' i� ' ' . .. _. � ..
,' ,
. ' � .
, • �,t�3 1'•o � � r`r.' 7
' � � �, m
,+ , _ ' ' °-co°-o ' � nic � �•� e� a' .
� £ O N Q �7 � ;N �� N� N N K
� ' 703 ?.OSN� � C :�7.(�7 �QS�' �-p � 4 � .
o pu � a 4 �
1 � � SC ?'�_�".O Cf-fB O n.T�J'n O n �NO�C �O W o�n•T� 7� �"� .
� . ��. t] nTOv,r-�l��a C �}-n 6_� �j L'G p o,� j �'.O� r�.'�U N 3 O 0^ S �� '
1 �1 O Q . . �, 3 a'v c � o £ , a c.� o Q o W°.o�`-•" � °.o „o.� ' N 3'o � : '
. . � � "o � . • = oa7_� . ° a;�...o •- � f .. �.v.°'oa� ,� � qo _ " _ C
c�
� �C1 � . � �'" � wS'�^ 3^ �; �� f N o o :��.x S N.° � a� o N o o c-
. , c� o '-N —o 3 a ,- a, o N 3 p
' " , o' . � a '" "` a �� f � c• oo <.oQ.N � o ��� 3�'.0 � N _ no rt
� N f �' � � o ci 0. .,�•fl � .� _-o� � �'o c v o f �' . 76 .
. , . . . . . ' �, G r-S'II p u� rJ ." O K�o� C.Q �'.�6.O �...O.O'X.�"' fl v� � O .��„Q� C! � Q
� . � o n a-o ��. „ � o � c� � � o �'c'9 3 r�
- . a . � • � ° � '^ 3 $ ° _Tfl N ao °'o o ° '.� "`�'T� o °Di�� n �.
' � oo '" o �' ?0 3-0 � 0 1v.Nob vD.- 3-.� 3, � � � -^ ��
' o _ v� . � "� o N v ; � �.,�•m o - '` o o A
, _ _ _ o � a o �� ° °o.�n � ' :'r o-c.g -••,� ° ��`'m � as° '" 3 ^_. � 3 D .
. .. . . . . 7 . �An'6HO9 � Q� TS7pN � £ N'���.'Q.�, � G � �n'D� tnS � • .
. . o �'c � ^ 0 �� � 3�0 � os°y� �,c.o�o N3.° cpo'^ m.�.m � "
. .. . . . - - y 'o,' o�a �..oa o �o n-� m °O ' ^?•o_N op � p o ` 7� z.
� . a� (1 O ...-> > -�� � O 3 C.� �
� � . ' - .. . . � � � O Q;' ry � � O �,3 T^ _j p fJ q.T p,.fl'd�•� a C1 3'� O O
• . , . . - � o� on " � 3� � � �o,��'f .Tov+o '°c'oo � o °�'�`—' o
� ?
' ., ' - . Ci.'ti -mi "'� ' C �-- �� u. O'O !l � •C Q q 6 O � � ._,ti tn y;
' � p ��S N. 'S .,. • W' ..O yr 3-p ^ Q - S'p O 7''
• ' . . 'O a N S � O ' d O N O 7 . 4'1j in O � CJ
. . . . . , •.C �� �� � . !7 � � .N o �.. � �O �j 'y u,' 7'
- _ • � p oov-� ; � - a yc � o a n. .
� , p ^-O � O f� G 7 O Q S'G
" . . . . 7 � � O � 7 O.O -'
. � ' � � � ^ � � �
' . - .. ' . . . , 0 't