HomeMy WebLinkAbout1295A WORKERS'COMPENSATION DECLARqTION � APPLICATION FOR PERMI 1 �
T hereby aiiKm ihat I have a certiiicale of conseM to s'elf �
insure,or a certifitate o�Worke.s'Compensation Insurance, ;bA3�c ' HEATING • VENTILATING - AIR CONDITIONING
. or a cerlified co�Sy th reof(Set.38b0,Lob.C.)
r f1^ ,�. � CE-818(REV.10/81)
P❑oliq NoILI�Q.Z,7SGtompany _ COUNTY OF LOS ANGELES BUILDING AND SAFETY �'/�6
Certified copy is l+ereby furnished.
�
� Certifiedcopy is filed with iha county build�ng inspec- FOR APPLICANT TO FILL IN BUILDING 7 �'
tion deparlment. � ADDRESS V
Da1e� � 7 l� (PRINT OR TYPE ONIY�
APPlicant � LV i�A n_� LOCALITY �.�,�
NO. TYPE OF APPLIANCE OR EOUIFMENT�. . � � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � NEAREST
COMPENSATION INSURANCE CaOSS ST.
. (This�etllon need nof ba tomplated if the work Invoivad 6y ABSORPTION UNIT,BiU DISIRI�I NO. PROCESSFO BV
1he permil is for one handrad dollars(5100)or le�s.) /
1 tertify that in the performance of the work for which this AIR HANDUNG UNIT,CFM v -
permit is issved,I shall not emplby any person in ony manner BOILER,BTU
so as fo become subject to Ihe Workeri Compensotion Laws._ nvvaovAtS o�r� INSPECT04'S SIGNATURE
Dofe Applicant � COMPRESSOR,BTU ROUGH
NOTICE TO APPIICANT; If, after making this Certi{��ate of l VENTILATION SYSTEM � ,� � (i'� FINAL -
Exemption, you�should become subject to the Workers'
Compensation provisions of the Labor Code,yau must forth- EvqppRATIVE COOLEtt, - VALIDATIOPI
wilh comply with such provisions or this permit sholl be
deemed revoked. � � FLIRNACE: FAU-GRAVITY
LICENSED CONTRACTORS DECLARATION ROOR BTu ,�
I hereby offirm thot I am licensed under provisions of Chopter 9- HEATER: �- SUSPENOED UNIT_ - - � �
'(commencing wilh Section 7000)of Division 3 oi Ihe Business ' WA« _
and Professions Code,and my license is in iull force and effecl. . �- . � d
license Number �7� lic Class � � � -- � , V
) n oG
Contratlor � Dale�..'1,7/�g? . . _. . . . . .. . . . . - �
F
❑ I�n ezempt under Set. ;� 2 Q 5 A . a '
� Plan check fee N
� .C.for this reason�
' PERMIT ISSUING FEE S �a ,�'a �' ' ' ' �a �
Da�e:
ature
TOTAL FEE �o I '� •1 b 5 O
� OWNER-BUILDER DECLARATION RAN CHECK AP7LICANT � . e • e 1 b 5 p�
' I hereby afFi�m thot I am exempt from�he Contracror's License '
Law ior�he following reasan(Secrion 7031.5,Business and NAME � �9,Q 2�-8 7
Proiessions Code): � - � " .
❑ I, os owner of 1he property, or my employees wilh
ADDRESS �� �
waqes as their solc comper.;elion,will do�hn work nnd �� � _
the srrucrwe is not intended or offered for sale(Section Ci�v TEt.NO.
7044,Business and Prafessions Code). , - p - �� � ��
. � OWNER ` �i LOv
❑ I,as owner of the property,am exclusively comracting �
wi�h licensed controdors to construU the project(Seo- � �"�A��- . � � .
tion 7044,8usiness ond Piofessions Code). ADDRESS • -
CONSTRUCTION IENDING AGENCY � ClTY - �� �-� TEt.NO2�3�Z G
I hereby o(firm Ihat there is a construtlion lending agency for ► �
the performance of the work for which this permit is issued � �pMRACTOR � - '�
(Sec.3097,Civ.C.). � � � - � . . ' .
AD�RE55 -. . . . . .. . . .. _ .. . � .
lender's Name � ' �
. CITV _ TEL NO� Z� O - . . . .
Lender's Address �
SiATE LIC.
I certify 1Fo1 I have reod this application and stale Ihot the IICENSE NO. -�QA55 . . _ . . .
abova in(ormation is correct.I agree�o tomply with oll Coun�y
ordinonces ond Srote laws relating 10 building tonalrutrion, ,
ond .r y outhorize represenlaliv of this Coonty to eNer � � - � � - � � - � �� - " �
upon the bove- oned proper for inspection purposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
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