HomeMy WebLinkAbout1375A � WORKERS•�oMPENSAT�oN oE«ARAT�aN - APPLICATION FOR PERMIT �-
I herebyvffhm that I have a cerlificate of mnsent ro self
insqre,or a cerrifico�a of Workers'Compensation Insurance, �eA3eac HEATING • VENTILATING - AIR CONDITIONING
or a certified copy thereaf ec.38 , b.C.)�
//�� E-818(REV.10/81) �� � �
❑cyN pan
Cerliiied copy is hereby furnishe . COUN7Y OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with ihe county bvilding inspec- FOR APPLICANT TO FILL IN BURDING (` /''
tion departme 1. ADORE55 J! �4 C.. i
+ � .,//71 .y/7��-7� (PRINT OR TYPE ONLY)
Date ��/ Applitont._(r��"✓ ��� NO. iYPE OF APPLIANCE OR E�UIPMENT � FEE ��AIITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �
COMGENSATION INSURANCE CROSS 5T � !f
(This aecTlon need not be complotad if fha wo�k lnvolvad 6y ABSORPTION UN�T,8TU oiStaiCi r�0. vaOCf55ED er
the permN Is for one h�ndred dollors(5100)or Ieta.J '1
� AIR HANOLING UNIT,CFM ` U a�O 1 Q
I certify that in the performance of the work for whith this �
permil is issued,I shall not emplay any person in any monner BOiIER,BTU
— so as to bemme subjed to�he Workers'Compensalion lows. nvvaovn6 onre INSPECiOR'S SIGNATURE —
Oale epplicont COMPRESSOR,BTU � V ROUGH �/.�
NOTICE TO APPLICANT: If, afler making Ihis Certiiicate ol VENTILATION SYSTEM FINAL GA--.�..
Exempiion, you should become su6jecl to the Workers'
Compenso�ion provisions of the labor Code,you must forth- EyqppRa7ivE COOIER VALIDATION
wilh tomply wilh suth provisions or this permil shall be
deemed revoked. FURNACE: FAU 1VITY�� M
� UCENSED CONTRACTORS DECLARATION FtOOR � BTU �7✓ lJ
I hereby offirm thof I om licensed under provisions of Chopter 9 SUS�NOED UNIT_
HEATER: Wa��
�(commencing with Section 7000)of Division 3 oi the Bosiness }
and Prolessions Code and my license is in full force ond eifec�. � � -yry 7- q� �.
�,Jrp.-)� CJ L p
License Number ` Lit.Class�-+ �"� � - - ► V
� "137,5A
�,,.��.� l�3zi /i�.�o— , . . �II �:
�Contracror __T�ote Tr • • �
� v
I am exempf vnder Set. � • •F a 2� W
Plan check fee �
B.BP.C.for Ihis reason� • � o v;.<`= Z
PERMIT ISSUING FEE S O �
Da�e:
Signature TOTAL FEE 0 a.�7—s�O
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am eaempt from�he Con�mctor's License /
Law for Ihe following reason(SeUion 7031.5,Business and NAME
Professions Code):
❑ I, as owner of the property, ar my employees with ADDRESS
oges os Iheir sole compensation,wi�l do the work and CITY TEt.NO.
the struc�ure is noi intended or afiered for sale(Settion
7044,Business ond Professions Code). �
OWNER �
❑ I,as owner o(the prope��y,am exclusively conhaUing MAIL
wiih licensed contrac�ors to construtt the project(Seo- - ADDRE55 1/� �
tian 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CIN � �s'� TFI.NO i/
I hereby affirm that there is a construction lending agency for � ►
the performance of Ihe work for whith ihis permir is issued CONranROR �
(Sec.3097.Civ.C.). � � . . . .. . .
- . ADORESS � � . .
Lender's Name �
CITY �` . 7EL NO. � . . . . . .. .. ._ .. . . .
lender's Address
STATE tIC, r'7 1
I certify thot I hove read Ihis application and slate that the IICENSE NO. � CLA55 G[J -- � - � � ... . .
above informa��on is correct.I ogree io comply with all County
ordinantes and S�o�e laws relating lo building constroction, �
and hereby authorize representatives of this Coonty to en�er - � � - � �
up �he o ve-mqntioned prope�ty for inspedion purpos . SEE REVERSE FOR EXPLANATORY LANGUAGE
L r-Z —
$igna�ura o Applicanl or Agenl Dote ' . . . . . � . . . .
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