HomeMy WebLinkAbout1052A (9) """"°`"' "'mr`"s"Ti°"°E"°'R"Tio" APpLICATION FOR PERMIT �
I hereby affi.m+haf I ho�e a cert�(ico�e of consent to self �
insore;'or a ce�lifimte of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
i or a cerri(te copy thereof(Sec.3800;lob.C. 76n364C
CE•818(REV.10/81) �
P❑olfcy N Compony COUNTY OF LOS ANGELES BUILDING AND$AFETY I
Certified topy is hereby fwnished.
� Certified copy is filed with tha county buildin9 inspec- FOR APPLICANT TO FILL IN BUitoiNG •��� 1 /j
tion d ortmenl. ' AooRE55 6 ,Jl.�1'1'ZfY�1 i,J�
�j�/�� (PRINT OR NPE ONLVJ .
Date Applican��L�YLV V� IOCALITY
NO. NPE OF APPLIANCE OR EOUIPMENT � � FEE
C RTIFICATE OF EXEMPTION fROM WORKERS'- NEnRESi
COMPENSATION INSURANCE � CROSS 5T. -
(This secfion n��d not!i�complafed 1(Ih�work lnvolved by ABSORCTION UNIT,BTU DiSIR�CI NO. �QOCESSEp 0Y
1he parmlt li for ona hundrod dollor�(5100)or lass.) qIR HANDLING UNIT,CFM
. I certify thot in�ha performanca oi the work for whith this . _ I� �
permil is issued,I shoil nol employ any person in any monner
so os to become sobjecf fo�the Workers'Compensotion lows. BOUFrt,BTU AVPROVAlS o<rt INSVECiOR'S SIGNATUkE
Dale ePP�i�a�� COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANi: If, oiter moking this Certificn�e of VENTIWTiON SvSTEM FINAL
. Exemption, you should become subject �0 7he Worke�s' . �1—
Compensotion provisions of the labor Code,you mus�forth- EvnPORntive COOiER !VAL TIVrv
wi�h eomply with such provisions or ihis permit shall be .
deemedrevoked. - � FURNACE: FAII�GRAVITY
LICENSED CONTRACTORS DECLARATION FIOOR 6TU
I hereby affirm thal I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
�(commencing with Sec7ion 7000)of Division 3 of the Business HEATER: WA��
and Mofessions Code,ond my license is in fulllorce and effecL , - , d
Licensa Nom6er��_Lic Cias�� � � � � ► U
�! a
Conhacror Date � � . �
❑ I am ezempl under Sec.� � . _ . , w
Plan check fee a
w
8.8P.C.for this reason' pERM1T ISSUING FEE S J b �
Date:
Signmure TOTAL FEE ��p '
. � OWNER-6UILDER DECIARATION PfAN CHECK APMICANT LQ �.���
I hereby oifirm that I am eaempt from ihe Controc�or's l(cense . �
law for the following reason(Section 7031.5, Business and NAME .
� Proiessions Code): � -
❑ I, os owner of the p�operty, or my employees with ADDRESS ! � L �
wages as iheir sole compen5a�io�,will do the work and CITI Til.NO. �
the strucrure is not inirndAd o�eff=rod for;o!e(Section � � d�7 . -
7044,Business and Professions Code). ?� O u 2 a
OWNER �QU� ���
❑ I,as owner of iha property,om exclusively con�racling �` �f ' �• • • • ��
wiih liceneed conimclors lo consfruct the projecl(Sec= qDDRESS � V
tion 7044,B�siness ond Pro�essions Code). . I • a � Q Jr O
CONSTRUCTION IENDING AGENCY �- Ciiv � TEL.NO. �y
I hereby allirm ihot�here is o cons�ruction lending ogency for V , � � � r '
the er(ormonce of Ihe work for which fhis ermif is issued ' . . -. � 6'J�"
P P CONTRACTOR
(Sec.3097,Civ.C.).' . {� , .. . . . ., ��8 2.3—8$
� . � ADDRFS$'V' . .. � . . - � . ... .
Lender i Nome
� 7 1�'Ob _ '
- CITY . 7EL.NO.
Lender's Address � .
I tertif Ihot I hove read this o lication ond slote Ihat the STA7E liC. �
y pp UCENSENO. CLA55 -- � �� � - ��---�- � - - . . .
above iniormolion is cortetf.I agree to comply with oll Counry
� ordi es and Srote laws relating to building construction, � �
an he .by aufhoriz represen� 'es of this Coonty�o enter . � �-��� �� -� �� � � - � -- �
u n th above-me ioned prop ry for inspection parposes. SEE REVERSE FO�!EXPLANATORY LANGUAGE.
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