HomeMy WebLinkAbout1297A (22) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � �
I hereby affirm tha�I have a certi(icaie of conseM�o self
insu49-bru ceriificate of Workers'Compensaiion Insuronce, ���� HEATING - VENTILATING - AIR CONDITIQNING
or a cerlified mpy Ihereof(Sec.3800,Lob.C.) CE-818�REV.10/81) � �- -
P❑ollcy No.�Y D 4Z_oCompany S� ���
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wi�h�he couMy building inspec- - FOR APPLICANT TO FILL IN - euuDwG � � 7/�O
tion depariment. - � (PRINT OR TYPE ONIYj /�DDRE55 ���J
Dafe�J—Applicanl�� -�����W't� � LOCALITY ! �
NO. iYPE OF APPLIANCE OR EQUIPMEN7 FEE I V
� - CERTIFICATE OF EXEMPTION FROM WORKERS' Nea.aeST
COMPENSAiION INSURANCE - � Ce055 ST. Q �
- (Thit soclion need not be complefed if tha work fnvolved by Ag50RPT10N UNIT,HTU �ISIRICI N0. VROCESSED 6Y
tha parmit is for ono hundrad dollars(S1D0)or lass.) J�
I certify that in ihe performance of the work for which ihis A�R HANDLING UNIT,CFM � . �
permit is issued,I shall not emplay any person in any manner �
so os fo become subjecl lo the Workers'Compensolion Laws. BOILER,BiU APPROVAlS OAiE I $PEC70R'S$IGNAiURE
Dale opplicant COMPRESSOR,eiU � ROUGH
f'^TICE TO APPUCANT: If, aker making ihis Cerlifimle of VENiIIATION5Y5TEM l�„ (f� F�NAL � /� -
Liplion, you shouid become suoject to Ine Vvorkers"
�mpensation provisions of the Labor Code,you musl forlh- EVAPORATIVE COOLER VALIDA
with comply with such provisions or this permit sholl be
deemed revoked. � . FURNACE: FAU_GRAVItY �
LICENSED CONTRACTORS DECLARATION F�OO� e7U
I hereby af(irm Ihaf I om licensed under provisions of ChaplBr 9 HEATER: . SUSPENDED UNIT_ �
� '(mmmencing with Section 7000)of Division 3 of�he Busineu ' wA« �
and Protessions Code,and my license is in full force and eHecf. �_ `/J 2 ,/„� �, a
(y/�,� �C.w.C�(o G�..(�c-c.C. � 0
. License Nomber��bJ !(J,L� Lic.Closs� � . U
OC
CoNractor Date� � - � �
� . f129,7A �
I am exempt under Sec. u�
Plan check fee �{• • • • •8 a
N
e.&P.C.for this reasorc PERMIT ISSUING FEE$ g Z�Q ? :
Date: J O � • •
TOTAL FEE �
Signature • • ?8 2,���
� OWNER•BUILDER DECLARATION PIAN CHECK APPLICANT - - •
I hereby affirm ihot I am exempl fram ihe Conlractor's License o fl 31—8 8
Law for ihe following reosan(Seclion 7031.5, Business and NAME ��N�/, ,
Professions Code):
C1, as�owner of Ihe properly, or my employees with ADDRE55 ' i
woges as Iheir Sole Compensation,will do Ihe work and �ITY TEL.NO. ,�r �
the struU�re is not intended or offered for sale(Section �
7044,Business and Prafessions Code). � � - � r -- - -� � - -
OWNER �I�L�O� 1�
❑ I,as owner of�he property,am exclusively conlracting
with licensed coNradors lo constroct Ihe project(Sec- ��� - �q- �
� tion 7044,Business and Professions Code). . A�DRE55 Lr
CONSTRUCTION LENDING AGENCY - CI7Y - � -- �TEL.NO � !
I hereby affirm fhof there ii a conslruction lending agency far . ,
ihe performance of the work for which ihis permil is issued CONTRACTOR � �
(Sec.3097,Civ.C.). . � . , . . . . . .. . . . .
• - A�DRE55 �� . . . . . . . � . ._ _ _..
Lender's Name
CITY TEL.NO.G��. � .. _. . . . . .
Lender's Address � � � �
I tertif that I have reod�his o limtion and stoie that Ihe. STATE LIC. _ �
y pp UCENSE NO. 7 CLA55 - . - . . . . . ..
above informalion is correU.I agree to comply wiih oll County _ �
ordinances and S�a�e laws relaiing to building constr�Uion,
nd hereby authorize represeNatives of�ihis County lo enter . � �� �
p the above-menti ned property for inspection pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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