HomeMy WebLinkAbout1376A (7) WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR PERMIT • I'
I hereby citirm thot I have a certificate of consent to self
ins�re,or a cerrifimie of workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING L�
or a terfified co y thereof Sec.3900 Lab.C.) 76A764C �
Q �,/� CE•918(REV.10/Bl)
❑cY N� ` Pan 0 vf i`'`—r - . .. . .
Cerrif�ed copy is hereby f�rnishe . GOUNTY OF LOS ANGELES BUILDING AND SAFETY
�Cerfified topy is fled wi�h rhe county building inspeo- FOR APPLICANT TO FILL IN su��o�rvG �J
ion deporlm nt. (PRINT OR TVPE ONIY) ADDRESS � 0 C�I
Date �/ Applicant LOCAIITV
NO. TYPE OF APPIIANCE OR EOUIPMENT - FEE
CERTIFtCATE OF EXEMPTION FROM WORKERS' NEnkFSi
- � COMPENSATION INSURANCE � . CROSS ST. / . l'
�Thl�saclion nead ne1 be eompleled�(the work Involved by ABSORPTION UNIT,BTU Di51R1�1 NO. PRp(($SED BY
the parmil��for ona h�ndrvd dollars(5700)or lesf.) q�R HAND�ING UNIT,CFM J� /�(\
I certify that in the performance of tha work for which this (/ � " ���4� �
permit is issued,1 sholl nof employ ony person in any manner � _ .
so as ro become subject ro the Workers'COmpensation Lows. BOILER,BTU APPROVAL$ DATE �NSiECTOR'S SIGNATURE —
� COMPRESSOR,8TU u O" ROUGH `�J�� �S1
Dare /+pplicant
NOTICE TO APPLICANi: If, af�er making this Certificote of VENTitATION SvSTEM FINAL
Exemplion, you should become subject to 1he Workers'
Compensolion provislons oi the Labor Code,you musl forih- EVAPORATIVE COOtFR VALIDATION
� with comply wiih such provisions or this permit sholl be
deemed revoked. FURNACE: FAU �VI �— V
IICENSED CONTRACTORS DECLARATION��- FtOOR eTu
I hereby affirm that I am licensed under provisions of Chopier 9 ��- HEATER: SUSPENDED UNIT— �
'(commencing wi�h Section 7000)of Division 3 of�he Business ' WA«
and Professions Code,and my Iicensa Is In full force���444nd effett. }
� 2 ► V
license Number � Lic Class� - � � - '
I� p�' °
Conhodor o�e �'
� ?1 �7,6A � �
I am exempt under Set. a
Plan check fee �. ; .,. ,g �n
6.8P.C.for ih�s reoson PERMIT ISSUING FEE S � �
�aie: I • �5 3 2 5
TOTAL FEE
Signafure . � • o»�j 2 J�
OWNER-BUIIDER DECLARATION � PIAN CHECK APauCnNi
I hereby affirm thot I am exempt from Ihe Contra[lor's License � . 0 9,0 7—8 8
Law for Ihe iollowing reoson(Section 7031.5,8usiness and NAME
� Professions Code): �
❑ I, as owner of the property, or my employees with ADDRE55 � .
woges as Iheir sole compensafion,will do the work and �ITV TFL.NO. �
the structure is not intended or oflered for sale(Sectian
7044,Business ond Professions Code). - pWNER
❑ I,as owner of the propeity,om exclusively conhociing MAIL
with licensed conlractors 10 construct Ihe project(Sec- qDORESS � �
tion 7044,Business and Protessions Code). � -
CONSTRUCTION LENDING AGENCY - aTY 4 �" ie.NO. i �v "
I hereby affi�m Ihal there is a construttion lending agency for � ,
ihe performance of the wark for which this permit(s issued COMRACTOR .
(Sea 3097,Civ.C.). � � � .
- AODRE55 �� � - - - '
Lender's Name
. CITY TEL.NO. �y . _.. . .- _ . . .. . .
lender's Address
STATE f LIC. �7.�
� I tertify that I have reod�his application ond s�o�e that the ❑CENSE NO.L ` QASS �C..[J . - -- - �� � - � ��� -- � �
above inForma�ion is correct.I agree to comply with all County ,
I ordinances and Sto�e lows relating to building construction, - � , . . . .. .
ond hereby avthorize represen�atives of this County lo enler .
upon ihe abo e-merx�oned proper�y forinspeciion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ . _ .. _
I � �ZT� . .
I �S�qnaNre of pliwM or Agent Date� .
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