HomeMy WebLinkAbout1406A (7) WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR PERMIT �
I hereby affKm that 1 have a cerlificate af consent fo seli � .
insure,or a certificate of Workers'Compensarion Insorance, HEATING - VENTILATING • AIR CONDITIONING ��
or n ceriifi d copy thereof ec.3800, .C.)� 76n364C
I �7 �CE-B16(REV.10i81�
P�ol'��'y N ` L pany . . .
Certiiied topy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�r—�(/Certified copy is filed with the covnly buildfng�nsPec- FOR APPLICANT TO PILL IN BUILDING / A�� �
(— ion deparlm nL . (GRINT OR TYPE ONLY) ADDRESS IQ U�
Date�l�l�Applimnl LOCALITY ,
NO. TYPE Oi AFCLIANCE OR EQUIPMENi FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST n /'��� �/.
COMPENSATION INSURANCE CRO55 ST. �S( (/7
(Thts aactlen naad not bo completod iI tho work involvad 6y ABSORPTION UNIT,eTU DiS�RIC1 NO. oROCfSSED Bv
the parm�t Is tor ono hundred dollars(5100)or less.) q�R HANDIING UNIT,CFM
I cerlify�ha�in the performance of the work for which this
_ permit is issued,I shall not employ any person in any manner BOiIER,BTU -
so as to become subject to the Workeri Compensation Lows. ? avaaovnis DATE INSGECiOR'S SIGNATURE
. COMPRESSOR,BTU ✓� �u� u �^ ROUGH �U J���
Data Qpplicant
NOT�CE TO APPLICANT: if, af�er making this Cerlifitate of VENTRAT�ON SYSTEM FINAL ' �
Ezemption, you should 6emme.subject to Ihe Workers' �
Compensa�ion provisions oi the lobor Coda,yo�musl forih- EVAPORATIVE COOLER VALIDATION
with comply wi�h suth provisions or ihis permit sholl be
deemed revoked. � FURNACE: FAU G tt ' .
� LICENSED CONTRAC70RS DECLARATION FLOOR B7U � l�
�� I hereby affirm ihot I om licensed under provisions of Chapter 9 HEATER: SUS�ENDED UNiT_ . �
�(commencing with SeUion 7000)of Division 3 of ihe Business �"'A« }
and P�ofessions Code,and my license is in full force�d effect. )J C O
(� � r �
.Litense Number ��� "� Lic.Class� �� ,
�
Coniractor ' ole � Q � �
❑ I om e=e'mp�under 5ea �� L Q 6 A �
Plan check fee ,�
B.BP.C.for this reason� � J� t}� � � � �a Z
PERMIT ISSUING FEE S
Do�e: TOTAL FEE �j � • ���.7�
Signolvre
� OWNER-BUIIDER DECLARATIDN ttAN CHFCK APPIICANT � ° � ����0'�``
I hereby aifirm Ihat I am exemp�from the ContraUor's License � '�_�i,3
Law for the following reoson(SeUion 7031.5,8usiness and NAME - O S.O
Professions Code):
❑ I, os owner of�he property, or my employees with
A�DRE55
� woges as their sole compensa�ion,will da the work and ��TV TFL.NO.
the shucture is not intended or offered{or sale(Seclion
7044,Business and PrOfessio�5 Code). . py�NER
❑ 1,as owner of the property,om exclusively contracfing MA` � ` �
wifh licensed conlraclors ta mnstruct ihe project(Seo- qDDRE55 /'
tion 70E4,Business and Proiessions Code). -
CONSTRUCTION LENDING AGENCY CiTY 7Et. 'O. i ��
I hereby aifirm fha�ihere is a const�uction lending agency for ,
the perfo�mance of the work for whith Ihis permil is issued � CONTRACTOR � '
(Sea 3097,Civ.C.J. - - -
� ADDRESS � 6 .� . ' � �
Lender's Name
CITV TEL NO. � `S'[,!� . . . . . _ �
Lender's Address �
' STATE � / '?L UC. /�_�^ .
I cerlify thot I have read�his applicalion and s1a1e that ihe LICENSE NO. �( V CtA55 t-� `�J --� � � - � �
above information is correct.I agree�o comply wi�h all Co�nty .
ordinances and Stote laws reioting to building constroction, � ,
ond hereby authorize representaiives of this Coun�y to enler .
upon ih above- enY�ned proper�y for inspeciion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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� '�oNre of Applkon�or Agenl � Oo+e �
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