HomeMy WebLinkAbout1407A WORKERS'COMPENSATIONDECLARATION ' APP�,'CATION FOR PERMIT �
I hereby oifkm�hat I have a cerlificafe o(consent�o self
��s��a,or p cerfificote oi Workers'CompensoH�i�s��o��e, ,ba3e�c HEATING - VENTILATING - AIR CONDITIONING d y
or a'cer�ified copy thereof(Sec.38 b.C.) � �
'2 ' CE-B�B�REV.10/81) - - ��� -
Policy -Q�I�/fiompan � COUNTY OF LOS ANGELES BUILDING AND SAFETY
� C er ti f i e d c o py i s h e r e b y f u l ni s h e .
Certified copy ts filed with�he counfy building inspeo- FOR APPLICANT TO FILL IN euaowG L,
tion depor.lrme/nL �� •�, '/ , (PRINi OR TYPE ONLY� ADDRESS � 71� �
Da�el,•� a� Applicant�-��� ,-!� LOCAIITV �
NO. NPE OF APPLIANCE OR EOUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE . � . CR05S 57 �� /!C/1
(Thls saclton nead nol 6a completod if the work fnvolved 6y ABSORPTION UNIT,BTU DISfRI�T NO. CROCESSED BY ,
Ihe pormif is for one hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM 1 O � \
I certify ihat in�he performance af the work for which this 0. O�1 �
perm(t is issoed,I shall nat employ any person in ony monner � gOILER,BTU "-
�- so os m become�subjed ta ihe Workers'Compensotion Laws. � nvvaovna onTe INSPECTO4'S SIGNATURE
Ddte ApplitoM � COMPRESSOR,8TU • �/��"�� /� ROUGH p Lr ��
NOT�CE TO APPIICANT: If, affer making this Certificafe of VENTIlATION SYS7EM FINAt p� U�— I
Ezemption, yoJ should become subjed ro Ihe�Workers'
Compensation provisions of Ihe Labor Code,yo�musl iorlh• EVAPORATIVE COOLER � VA���AT��N ,
wifh comply with such prov'�sions or this permil shall be
deemedrevoked. - FURNACE: FAU__GR VITY
LICENSED CONTRACTORS DECIARATION FLOOR � eTU � .
I hereby affirm that I am litensed under pro�isions of Chopter 9 HEATER: SUS�ENDED UNIT_
� '(commencing wilh Section 7000)of Divisian 3 of ihe Business ' WA��
and Pro(e:sions Code,ond my litense is in foll forte ond effect - , � y
License Number r '/ Lic Closs�� - -� - , V
�. a .
Controcro ate •Z� . . . :� �:Q 7 f'y v
� � I om ezempt under Sec. - . . . . _ �'• • • o •Fj w
Plan check fee °-
8.8P.C.for ihis reason� � � • •4 9,7� ?
PERMIT ISSUING FEE S
Da�e:
TOTAL FEE � • • •4 9.7��
Signature ' �
OWNER-BUILDER DECLARATION PLkN CHECK APPLICANT � O 9•O 7-R�
I hereby oifirm that 1 am exempt from the ContraUor's license �
taw for the fallowing reason(Settion 7031.5,Business and NnME -
Professions Code): _ - �
❑ I, as ownei of ihe property, or my employees with A�DRE55 .
- wnges as thn�r sole comp?nsotion,will do the�+ork ond CITY TEL.N0.
�he structure is not intended or offered for sole(SeUion _
7044,Business and Professionz Code). . py�NER
❑ I,as owner ai ihe property,om ecclusively contracting
wilh licensed contmctors m constroct the projed(Seo�� �''�A�� .
� fion 7044,8usi�ess and Professions Code). - ADDRESS �
CONSTRl1CTION LENDING AGENCY � CRV�-� -TEt. O. (�� -
I hereby offirm thot there is a conshuUion lending agency foi
Ihe performance oI�he work for which this permit is issued COMRa OR ' ' ' � ' �� ,
(Sec.3097,Civ.C.). � " . .. . . . . ..
- � ADDRESS �. .�-. . .. . _ .. ' . � . , . _
lender's Name
. CITY TEI.NO. L (� � � -� - --- . . .. . � � _.
Lender's Address
S7ATE `7 l LIC. C�,�7�
I cerliiy that I have read this applico�ion and s�ate that the LICENSE NO. J � CLASS� W- ��� . - - -- - � �- - � � � � � .
above informo�ion is correc�.I agree�o comply wi�h all County
ordinonces and State laws�eloting ro building construclion, .. . . ' _ . . ,__, ,._ ,
ond hereby authorize representatives of this County to enter
upon� obav •me��ioned property for inspection purpoz s. SEE REVERSE FOR EXPLANATORY LANGUAGE . .. .
1 -�s
S�gnorure oF ApPlicont or Ag�n� Doia . . .. . . . . ._�. .. . ..� .... . . ..
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