HomeMy WebLinkAbout1298A (19) - ' WbRKERS'COMPENSATIONDECLARATION ' - APPLICATION f OR PERMIT �
I hereby aifirm ihot I have a certificme of mnsem ro self � . �
insure,or a ce�rficate of Wo�keis'Compensation i�s�.o��e, 76A�vac HEATING • VENTILATING - AIR CONDITIONING
or a ceriif�ieytl��cofypy�•-t�h[ETpe�of(Sec.3800,Lob.C.) CE-918(REV.10/el)
P❑o�ity No��✓Company� _ . . .__. ...
Cerrified capy is hereby furnished. COUNTY OF LOS ANGELES. . BUIL�ING AND SAFETY # ��Z
• � Cerrified copy is filed with the to�nry bailding inspeo FOR APPLICANT TO FILL IN - BUi�oiNG n c (� ,.�����
tiondeportmenl, � �(PRINTORTYPEONLY) AD�RESS ��u �+ %�Yi"�`�+� �
Date � 7—b7 APPlitent—D L���L� LOCAI�TY �, .+� -
. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TVPE Of APPLIANCE OR EQUIPMFNT . FEE NEAREST `,~a/ T•'C�
COMPENSATION INSURANCE CROS55T.
(Thtt setflon need no1 ba compl�fad IF the work involvod by ABSORPTION UNIT,BTU DIS7RIC1 NO. PROCESSEp BY
Iho parmif Ie For ona hvndred dollars(SI00)or le�e.) AIR HANOLING UNIT,CFM f� �
I certify that in the�performance of the work for which this '
permil is iss�ed,I shall not employ any persan in any manner BO�IER,BTU
so os to betome subjecl�o the Workers'CORIP2I15pf1011 LOWS. pDDROVAlS � OATF INSPECiOR'S SIGNATURE '
Dafe � ePP���o�� COMPRESSOR,BTU ROUGH
NOTICE TO APPIICANT: If, after making fhis Certificate of / VENTILATION SYSTEM l � 6 � FiNnL .
�Exemp�ion, you sho�ld become s�bject to the Workers' "'
' Campensalion provisions of Ihe lobor Code,you must forih- EVAPpRATIVE COOIER VALIDATION
with comply with suth provisions or this permit sholl be
deemed revoked FURNACE: FAU_GRAVITY .
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby offirm that I am licensed onder provisions of Chapler 9 HEATER: SUSPENDED -UNIi--_- --�-- --- � � -
�(commenting with Section 7000)of�ivision 3 of Ihe Business �'�'A« . �
and Professions Code,bnd my license is in full forte ond effect. � � . }
o.
License Number �� Lic Class� � � -- - ► ' V
,^r�,' �
Contraclor�f" ,�� Date�IB 7 � � �- - . O
H
❑ I am exempt under Sec. �� 2 9�H A W
- Plan check fee d
8.8P.C.for th�s reason' ' . . �• . • • •8 v�
Date: PERMIT ISSUING FEE S �O 3� �
Signature TOTAL FEE (� ' � ' • � b 5�
OWNER-BUIIDER DECLARATION PLAN CHFCK APPIICAM - ' - � ' •� b 5 O�
I hereby aifirm that I am ezempt from the CoMrac�or's l�cense � O 4.O 2�8,7 ,
Law for�he following reason(Sec�ian 7031.5,Business and NAME . �
Professions Code): • � - �
ADDRESS
❑ �I, as owner of ihe property, or my employees with .
�wages as thei�sole tompensa�ion,will do the work and � �iTY TEL:NO.
the str�cWre is not intended or offered for sale�Sectian �
7044,Business ond Professions Code). OWNER
❑ I,as owner of the properry,am ezcluzively tonirnUing Y
wiih licensed contmctors to construct ihe projec�.�5eo- 'W'�� ��r ' ' � � -- � -
� - tion 7044,Business and Professions Code�. AODaE55 - ,
CONSTRUCTION IENDING AGENCY GiY , � �-�O� iEL.N021� �D6 I
I here6y afiirm thot ihere is a consrrutrion lending agency for , .
the performance of the work for which this permit is iswed � COMRnCTOR- - •
(Set.3097,Civ.C.).. . . -
Lender's Name /DDRE55 �� x . !.t _ _ � �. - �_�- ..
� '
, CITY �/�� TEL NO.��_ -2�b��1
Lender's Addiess � �-��'•� " �� �' � - � �
STATE q T LIC. /��
I certify tha�I have read Ihis application and slate�hal the-. u�FNSE NO. p �J RaSS L1 � � __ . ._. ...- . -
obove information is correct I ogree to mmply wiih oll CouNy � -� � -
ordin ond Sta�e laws reloting to building constroction, � . �
. .
and ereb- authorize repr�enta�ives of�his Counfy�o enfer . - - - -- � - -�-- -- � � �
upo �he a ove-mentionP property for' spettion purposes. SEE REVERSE FOR EXPLANATORY LANGLIAGE.
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