HomeMy WebLinkAbout1377A WORKER$'COMPENSATIONDECLARATION � APPL'CATION FOR PERMIT �
I hereby affirm�hat I have o certificale of consent to self
insure,.or a ceriificata oi Workers'Compensarion Insurance, HEATING - VENTILATING - AIR CONDITIONING C�
ar 6 cerfif�ed copy thereo�Sec.3800 b.C.) • 76A36eC � �
CE•819(REV.10�81)
O�Y�{�/t 27 ompany � . .. . . . . . . . . ._ .
Ce�tified copy is hereby furnished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY
�i`Cer�iiied copy�s filed with the co�nry building inspec- FOR APPLICANT TO FILL IN BuitoiN� ?
r`� ion depar me . �, (PRINT OR NPE ONLYJ ADDRE55 cJ� �, al�s�r �
"Date ' Applicanl IOCnLiTv
. NO. TYPE OF AP%.IANCE OR E�UiPMENT � � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEnREST
COMPENSATION INSURANCE CROSS 51. s�
_. (Thfs soction naod not ba complotod if tho work tnvolved by ABSORPTION UNIT,BTU � DISTRiCi NO. CROCFSSFD BY �
the permlt is tor one hundred dollars(SI00)or lese.) qIR HANDLING UNIT,CFM �7 {�(� `
I terlify that in the performance of the work for which this 1 C/ '' `�\Q n'C
_ permil is issued,�sholl no1 employ ony person in any manner gOILER,BTU —
so os to become subjett to the Workeri Compensetion Laws. nvvaovwt5 DAiE INSPECTOR'S S�GNATURE
. APP�'�a�' COMPRESSOR,BN 0 �_ ROUGH 'f�-�—
Date
NOTICE TO APPLICANT: I(, ofter making this Certificale of VENTILATION SYSTEM FINAL L D
Ezemplion, you shoold�betome subjett to the'Workeri
Compensarion provisions of the Labor Code,you musl FOrth- EyAPORATNE COOLER VAUDATION
with comply wilh such provisions or this�permit shall be �
deemed revoked. �� � ' FURNACE: �FAU_GR VIT ^ .
LICENSED CONTRACTORS DECLARATION FtOOR BTV � (/
I here6y ef(irm IFro1 I am licensed under provisions of Chapter 9 - HEATER: SUSPENDED UN�T— - . -
'(commenting wifh Section 7000)of�ivision 3 of the Business wA�� " }
ond%oiessions Code,and my license is in ful I forc,/e and effect. � - � �� 3'7,'7 q O
License Number �+"V ` Lio Class `-' � - � � - - �� � � � e • • •� V
'l x
Controttor Dpte � " . - � • •5 3 2 5 V
❑ I om e*empt under Sea - . . . . •�+ 0 5 3?_5 c�i W
. Plan check fee °-
0.8P.C.for�hts reason PERMIT ISSUING FEE S O 0 9.0 7-8 S ?
Date: TOTAL PEE �
Signature -
OWNER-BUILDER DEGLARATION PLAN CHECK APttiCANT
I hereby affirm that I am ecempt irom�he Contmcror's License . . �
. Law for the following reason(Section 7031.5,Business and NAME � - �
Professions Code):
❑ I, as owner of the propeHy, or my employees wilh ADDRFS$ �
wage5 os their sole compenso��on,will do the work and CITY � TEL.NO.
ihe slruclure is not in�ended or oifered for sole(Section
7044,Business and Prafessions Code).. OWNFR
❑ I,os owner of the properly,am exclusively contrading
. with licensed contradors�o construcl the project(Seo- MAi� `
- . �ion 70A4,Business and Professions Code�.� ADDRE55 /�
.CONSTRUCTION LENDING AGENCY � q7y - TE�, � -
I hereby affirm ihot there is a conslr�ttion lending ogenty for ,
the periarmance of ihe wark for which Ihis permit is issued - CONTRACTOR �� "
(Sec.3097.Civ.C.).� � u� . _ . ..
� � � ADDRESS b �'-; . . . . . .. . . - .. .
Lender's Nome
� CITY TEL ND. a . _ ..
lender's Address
STATE �1 L LIC. /� �1'
I cerlify ihot I have read this opplicotion and s�a�e that the . LiCENSE NO. � 1 - CLASS-� C��XJ -. �- ��- - �-� - � � �-� � . �-
above information is mnecL I agree�o comply with oll Covnty .
ordinonces ond Sta1e laws relating lo building construction, � . _ _ , __, _
and hereby avlhorize represenlotives of this County m eNer . , . � .
upon a obo -mentioned p�operty f�spectio� n Purposes• SEE REVERSE FOR EXPLANATORY LANGUAGE
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