HomeMy WebLinkAbout0800A 1013A WORKERS'COMPENSATION DECLARATION App�ICATlON FOR PERMlT �
I hereby affirm that i have a certificote of wnsent to self
insure,or a certificate of Workers'Compeneation Insurance, ���� HEATING - VENTILATING - AIR CONDITIONING
or a cerfified copy thereof(Sec.3800,lab.C.)
CE-BIB(REV.10/81�
P�oAcy No.(�.Company�� 1W�MN?l� '
Cerfif�ed copy is hereby furnished. COUNTY OF lOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county buildin9��gPa�- FOR APPLICANT TO FILL IN BUIIDiNG� �A U , ��i
fiOn depprtment. A�DRE55 V-�
r '!� (PRINT OR TYPE ONLY) ,
Dote,..�.����pplicanf �r sr' LOCAIITV OA1tl
NO. TVPE OF APPLIANCE OR EQl11PMENT FEE ���
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � ^.�v6 , '
. COMPENSATION INSURANCE CRo55 ST. (y({ t
(Thfs soefion nad naf bo complatod IF tho work involred by ABSORPTION UNII.BTU p15TRl�T NO. PROCESSE sr
Iha parmif Is for ona hundrad dollnn(5100)or lect.)
1 certify fhot in tha performance of the work for whiCh�his A�R HAN�LING UNIT,CFM � �//�/J _
//I/(.Y���
permit is issued,I shall not employ any person in any manner BOILER,6TU
so as to 6ecome su6ject to the Workers'Compensofion Lows. nvPRovnR onre INSPEQOR'S SIGNATURE
Date Applicanf COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANi: If, after making ihis Cerfificate of VENTIIATION SYSTEM FINAL /
Ezemption, you should become subject to �he Workers' �
Compensation pravis�o�s of the Labor Code,you must forth- EVnPORA7IVE COOtER VALiDAT10N
wilh comply wi�h such provisions or this permit shall be
deemed revoked, iURNACE: FAU—GRAVITY
LICENSED CON7RACTORS DECIARATION FLOOR Biu
I hereby affirm that I om lic9nsed under pro�isions of Chapter 9 HEATER: SUSPENDE� UNIT_
�(commencing with Section 7000)of Division 3 of the Business " '�'�A«
and Professions Code,and my license is in full force and effect. ^� �
�y, � �'I� llV 0
License Num6er 6V�� Lic.Class� � V
�IR ���ii,Q�,r',�i pt
Contratror �ry��i.2^��`-Date�,��'��'� �
O . j{e . • •j[ V
1 am exempt undar Sec. w
Plan check fee
B.&P.C.for this reason � � � < <'�'�' N
.PERMIT ISSUING FEE S ? �
Date: • � a � ��;!l?
Signa�ure TOTAL FEE �l. � j1��5 �
OWNER-BUILDER DECIARATION PLAN CHECK APPLICANT �' 1 I
I hereby affirm that I am exempt from the CoNractoi s License � � �
law for the following reason(Section 7031.5, Business and Na�nnE
professions Code): 1,
❑ I, os owner of the property, or my employees with A��Rf55 � [,��,�„�.AIV S'
wages as their sole compensation,wiil do the work ond
the slructure is no1 intended or offered for sale(Section ��TY :� � tEL NO � 3
7044,Business ond Professions Code). OWNER
❑ 1,as owner of ihe property,am exclusively tontracting r� V�,.';n
with licensed contwctors to construcl the project(Sec- �'��
fion 7044,Business and Professions Code). AOORE55 f; a . • • •R
CONSTRUCTION LENDING AGENCY Ciiv tF�.tv0.
I hereby bffirm that there is a tonstr�ction landing agency for � • •`�'4 5�
the performonce of the work for which ihis permit is issued CONTRACTOR � � � ` � �
(Sec.3097,Civ.C.). . _ • s •,5 G��_
AODRE55 S� S � �.C E_��5
Lender's Name
- GTY \ . TEL.NO. � .- ..
Lender's Address .
STAtE LIC. /�
I certify that I hove read ihis application and state thai the ��CENSE Mp. CtASS `� �
a6ove information is cmrect.I agree to comp�y with all Co�nty
ordinances and Sta�e laws reloting�0 6uilding construction,
and hereby authorize repr senta�ives of this County to enler
u n t�gbove-m tion d pmperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/
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Signature of App imN or Agent Date
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