HomeMy WebLinkAbout1504A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
�orr�a cerrttiff ed coy h reof (Sec. 38 Lab. C. )
P
Y �, EIcYf7dCom an
❑ Certified copy is hereby furnished.
12-c'ertified copy is filed with the county building inspec-
tion, department,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nwd not be completed If e work Involved by
the permit Is For one hundred dolth
lots ($100) or less.)
I certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner
$
o as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
'(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
Y� c
License Number 46����J�� Lia Class Z -U
Contmcto }� '•Dote 119-11-1—Y
❑ 1 am exempt under Sec.
B.BP.C. for this reason
Dote:
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm that ,I,, exempt from the Contractor's License
Law for the iollowI ng reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, or my employees with
wages as their solecompensation, will do the work and
the structure is not intended or offered for sole (Section
7044, Business and Professions Code). .
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
the,eby'affi,m that there is a construction lending agency for
he performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
Pon the obove-mentioned property for inspection purposes.
Signature of Applicont or Age Date
APPLICATION FOR PERMIT q3 7P7
7eA364C HEATING - VENTILATING - AIR CONDITIONING
CE - 818 (REV. 10/81) -
COUNTY OF LOS ANGELES 'BUILDING AND SAFETY} c3U�U
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDING
ADDRESS
p
S/
LOCALITY
cin-C•s-.✓
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
[ROSS ST.
ABSORPTION UNIT, BTU
[70.
PROCESSED BY
M4
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
VENTILATION SYSTEM
FINAL
(671
EVAPORATIVE COOLER
►
VALIDATION
;E1 5 Q 4 A
4 ..... 8
I• -7t,75
• • •74.75
IQ21-87
..... . -. -
FURNACE: FAU GRAVITY
FLOOR BTUCr
HEATER: SUSPENDED—'UNIT.
WALL
3/ s
Plan check fee
PERMIT ISSUING FEE; /O5 Q
TOTAL FEE 7 qS
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
OWNER -7/w bp
MAIL _
ADDRESS
CIT /1�TEL. UO. - -
CONTRACTO --,2
ADDRESS I
CITY TEL. NO.
STATE ll q/��
LICENSE NO. nC� / / 6 CLASS !.�
SEE REVERSE FOR EXPLANATORY LANGUAGE
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