HomeMy WebLinkAbout1383A (7) WORKERS'COMPENSATIONDEC�ARATION ' APPLICATION FOR PERMIT �
I here6y�aiikm thal I have a certificare of tonsent to self
insure,or a certiiicale of Workers'Compensation Insvronce,� - �bA�bac - . . .HEATING - VENTILATING - AIR CONDITIONING
br a certified topy thereof(5 c.3800 b.C.)`
��/'p����J CE-818(REV.10/81)
P�ol'�ty No.�L_��pany . . . . . .. . ..
Certif�ed mpy is hereby furni:hed. COUNTY OF LOS ANGELES BUILD�NG AND SAPETY
Certified topy is filed wirh the touny bo�lding inspeo- FOR APPLICANT TO PILL IN suiioiNG
1'o de(p�arjlm(�e (PRINi OR NPE ONLY) � ADDRE55 � f � ,
� Dole ��1' o� -Applimnt ����Tv T
N0. TYPE OF APPIIANCE OR EQUiPMEM � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � NEnREST ` (
COMPENSATION INSURANCE . CRO55 ST. !f4lkJ
(Tht�teNlon naed net ba complefed if ihe work involvad by ABSORPTION UNIT,BTU OtSfRi�i NO. GROCES5C0 BY
fha permil is for ona h�ndred dollars(5100)or less.) .
I terlify fhat in Ihe performonce of ihe work for which this AIR HANDLING UNIT,CFM
permit Is Issved,I shall nof employ any pe�son in any manner � � �0.��"1
- so as to become subjeci�o the Workers'Compensolion Lows. BOILER,BTU , APVROVAlS DATE wsv�croa�s SicNnToce '-
Date epplimnt
. COMPRESSOR,BTU �v�` D ROUGH �(�� �---
NOTICE TO APPLICANT: If, ofter.moking this Certifica�e of VENTItATION SYSTEM FINAI �2�p� �_
Ezemption, you shou�d become subjett 10 the Workers'.. �
Campensalion pravisions of the Labor Code,yoU muit for}h- EVAPpRATIVE COOLER VALIDATION
with comply with such provisions or"ihis permi� shall be
deemedrevoked. FuzNnCe: Fnu_ virX J � '
�LICENSED CONTRACTORS DECLARA710N � FIOOk eiu V '
-�I hereby offirm thal I am licensed onder p�ovisions of Chopter 9 HEATER: SUSPENDED UNIT_ � �
�'(commencing wilh$edion 70Q0)of Division 3 of the Business � WA�� r
ond Professions Code,and my Gtense is in full force and effect.. � � •y,Z a
�'��,/p�i 7'� G
LicenseNumber' �03�� Lic.Class�r` � �� � V
�.G�,�.�7�U/f�i/ �� , :_i 3&3�; 0
Controcror nate
❑ �am exempr under Se-c.�— �� � � � �$ W
Plan check fee _ I • :5'a G 5 '^
B.BP.C.for this reoson pERM1T ISSUING FEE S ?
Dale: / • •e��C J�
Signature TOTAL FEE 2s
� OWNER-BUILDER DECLARATION PL4N CHECK APPLICANT �9•0'1—8 8 �
I here6y aHirm that I am exempl from fhe Contractor's License �
Law for the following reason(Section 7031.5,8usiness and NnME
-Professions Code): - �
❑ �, as owner of Ihe properfy, o� my employees with ADDRESS
wages as their sole compensation,will do�he work and
rhe struUure is nor iniended or aifered for sale(Section Ciiv iEl.NO.
7044,Business and Professions CodeJ. . -
OWNER
❑ I,as owner of the prope�ty,om exclusively conlratting
with licensed contractors to construcl the projett(Seo MA�� � � �-
� tion 7044,Business ond Professions Code). ` ADDRE55
CONSTRUCTION LENDING AGENCY -- CITY � - TE n10. ��
I hereby affirm thot there is a consiruction lending agency for ,
1he performance of Ihe work for which this permit is iswed� CONTRACTOR - -�-�- - -
(Sec.3097.Civ.C.). - . . . . . . . . . _
ADDRE55 � - . -.. - , �. '� . .
lender's Nome
arr tei.No.� L��`C� _ _
lender's Address - �
STATE LIC. -
, I certify�hot I have read this opplication ond sta�e thot the IICENSE NO. �� - CLn55 �—� -.. . -- -- _. . . . . . .
obore information is corrett.I ag�ee�o comply with all Couny .
ordinonces ond Stote laws relating lo building constructian, .
and hereby auihorize representmives of Ihis CooNy to enter � � � � � � "
upon i o ov entlaned roper r inspedion p r.os . SEE REVERSE FOR EXPLANATORY LANGUAGE
/� . _
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