HomeMy WebLinkAbout1378A (7) WORKERS'COMPENSATION DECLARATION �
I he�eby offkm Ihof 1 hove a cerfificate of consent to self APPLICATION FOR PERMIT
insure,or a certificate of Workers'Compensation�ns�rance, �6A��c - HEATING - VENTILATING - AIR CONDITIONING
or a certified mpy�hereof(Sec.3800 ob.C.)+ �
P❑olicy N �� ompon CE.BIB(REV.10i81) - � � -- �
Y COUNTY OF LOS ANGELES BUILDING AND SAP TY
Certified copy is hereby furnishe .
�Ce�tified copy is filed with the coumy building inspec- - FOR APPLICANT TO FILL IN - eUR��NG ��� rA
fl n d parlme t. ADDRESS
/, (PRINT OR TYPE ONLY�
Date + Applicant - ��l�T�' �
. NO. TYPE OF APPLIANCE OR EOUIPMENT - � � fEE
CERTIiICATE OF EXEMPTION FROM WORKERS' NEAREST
- COMPENSATION INSURANCE � CRO55 5. �/" 9 �
(Thi�eeHion n�ed no1 ba complefad if tha work Involv�d by ABSORPTION UNIT,B1U DiSLRiCI N . PROCESSE�BY
the parmit��(or one hundrad dollors(5100)or Ias�.J � I O
I certify ihat in the perfoimance of the work for which this. a�R HANDLING UNIT,CFM �
permit is iss�ed,1 shall not employ any person in any manner A d�
so as 10 become subject to the Workers'Compensotion lows. BOILER,BTU APpRpVALS DAiE INSPEC70R'S SIGNATl1RE �
� Date apP���a�� COMPRESSOR,BTU -D /O OUGH ��l ��
NOTICE TO APPIICANT: If, aiter making Ihis Cerfifi[ale of VENTIlATION SVSTEM F�NAL �f
-Exemption, you shovld become subjed to the Workers'
Compen5ation provisions of the Lobor Code,you must forlh- EVAPORATIVE COOLER VALIDATION - �
wiih comply wi�h s�ch provisions or �his permit shall be
-deemed revoked. � - FURNACE: FAU_GR
� IICENSED CONTRACTORS DECLARATION� - Fi00R B7U c-'I�?�— O
- I hereby a(firm that I am litensed under provisions of Chapter 9 SUSPENDED UNIT_
�'(commencing with Secrion 7000)ot Division 3 of�he B�siness HEATER: WA��
and Professions Code,ond my license is in(ull force�pnd effect. �'
�/'7� �7� 3 •Z a
� O
License Num6er 6 ✓ Lic Closs � '�^� � - ► V
OC
Contracror � Dare�� • � �1 3 Z£�A �
� ❑ �am exempt under Sec � � W �
Plcn check fee #• • • • •B . a i
B.&P.C.for this�eason' '^
PERMIT ISSUING FEE S � ! •�'a 2 5 �
Date:
Signature TOTAL FE� • • •J J.G J�
OWNER-BUIIDER DECLARATION PIAN CHECK APptICANT . � O 9 Q 7—O E
I hereby affirm�hat I om ezempt from Ihe Contm"ttor's license � .
Low for ihe following reason(Sec�ion 7031.5,Business and NnME
Professions Code): � � � � -
❑ I, as owner of the p�operty, or my employees with ADDRE55 -
- wages as�heir sole compensaiion,will do the work and Cltt iEl.NO.
Ihe shucture is no�intended or offered for sate(Setlion
7044,Business and Professions Code). � - �
OWNER
❑ I;os owner of the propeny,am eaclusively contracting
with licensed comracrors to construcr the project(Seo- MF`�� � - f �
tion 7044,Business and Professions Code). ADDrtESS I
CONSTRUCTION LENDING AGENCY -� - - CIN ��� 7Ei.NO.- v /�� � '
1 here6y affirm ihaf Ihere is a consiruction lending ogenty for �
Ihe performonce of the work for which this permit iz issued CONTRAROR� �� � � ,
1 cse�.3om.c��.�.,. _
ADDRESS � ���� �"'
lender's Name . '
CITY � TEL NO. � _ , . _
Lender's Address � �
� STA1E � l 3.� IIC. . . .
I certify ihat I have reod Ihis applicolion and slote that the . LICENSE NO. �- QA55 -� ...,_.
obove(nforma�ion is corre[1.I ogree to comply wilh all Coun�y �
ordinances and S�ata lows relaring ro building construction, �
ond hereby authorize represeNatives of this County to en�er ' " " � - . - � -" � --�� " " " � � � .
upon obov menl'oned properfy for inspection p�rposes. �
l SEE REVERSE FOR EXPLANATORY LANGUAGE
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