HomeMy WebLinkAbout1429A WORKERS'COMPENSATIONDECLARATION . APPLICATION FOR PERIY,IT �
I hereby affirm Ihot I hove a certificale of consenf 10 self -
insure,or a cer�ifkote of Worke�s'Compensarion Insurante, HEATING'• VENTILATINCa - AIR CONDITIONING
or a certi{ied copy�hereof(Sec.3800,Lab.C.) - 76n36tC
�� CE-818(REV.ID/81) - -- - �
PolicY No. 1�l � ompany j� � - - `--(��OQ
❑ Certified copy is hereby f�rnished. COUN7Y OF LOS ANGELES BUILDING AND SAFETY U
� Certified copy is filed with rhe counry boilding inspeo- FOR APPLICANT TO FILL IN BULLDwG C ��� �
fion de orlmenL /1 (PRINT OR TYPE ONIY) ' AD�RE55 J
Date � Applicant I�1JR�/UI� � IOCALITY �\
NO. 7VPE OF APPLIANCE OR EOUIPMENT � � � FEE �
C RTIFICATE OF EXEMPTION FROM WORKERS' NEnREST ^-r . �
COMPENSATION INSURANCE �
CRO55 5T. f�1�V �
(Thl�saclten noed nof be complotod if Tha wark Involved by ABSORP�ION UNIT,BTU DiSiRKT No. rRp�E55ED BY
Ihe permlt Ic tar ona hundrod dollars(f100)or less.) ��� .
I cenify that in Ihe performonce of Ihe work for which this AiR HANDLiNG UN�T,CfM � �
permit is issued,I shall not employ any person in ony manner gpltER,BTU
-so as to become subjecl to the Workers'Compensolion Laws. nvpaOv�tS DATE INSPECTOR'S SIGNATURE
Date Appii[ont � COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of �NTIlAT10N SYSTEM F�NAL
Exemption, you should become subject fo Ihe Workers' i � �
Compensation provisions of ihe Labor Code,you must forlh- EyAPORATIVE COOIER � �VA �p1-
wi�h comply with such provisions o� this permit shall ba
deemed revoked. � � - FURNACE: � FAI/_GRAVITY � . ---�
' - LICENSED CONTRACTORS DECIARATiON Fi00R BTU �
I hereby effirm thot I am litenied vnder provisions of Chapler 9 HEATER: SUSPENDED UNii_ � �
'(commencing with$ection 7000)of Division 3 of the Business `�`� }
and Professions Code,and my litensa is in full forte end effect.�- �`1 �� O C Q
License Number �/ d tit.Closs.l.�l� ,c v .�' OO , V
! �
Conrracrar �r Daie C�I`ry� - � . . V ..
❑ I am e:empt under Sec. - . � .. ' w
Plan check fee °'
N
8.8P.C.for�his reason� �
PERMIT ISSUING FEE S Q
Dale:
Siqnarure .r TOTAL FEE � "
OWNER-BUILDER DECLARATION �tAN CfiECK APPiKANT Lv(J�7y . .
I hereby aifirm that I om exempt from the Con�raUor's License �
law for the following reason($eclion 7031.5,Business and NAME
Professionz Code):
❑ I, as owner of the property, or my employees with ADDRESS r �' {�f�J` ra �� 4 2 9 A
� � wages as their sole rompensation,will do the(rk ond ��n, �7 Y��� TEL.NO. . �� � � � ��
ihe st�ucture is not inrended or offered ior sale SeUion
7044,Business ond Professions Code). ' ' � • •[�� 5�
❑� I,os owner of the property,om eaclusively contracting OWtvER 7°Lu�Z���.f1,
with licensed conlraUorS to conslruct Ihe projecf(Ser qDDRE55 J r 1�(�t j � • ••4�,J��
� tion 7044,Business and Professions Code). �
CONSTRl1CTION LENDING AGENCY �� CITY - " TEt.NO. S�"��`�(� . 0 9,0 7—8 S
I hereby affirm that there is a constr�ttion lending ogency for
the performonce af the work for which fhis permif is issued � � CONTRACTOR D� � � � " ,
(Sec.3097.Civ.C.). � j� y /+ . .. -. .. . . -- . . _. . . .
� ADDRESS (J 1 r� 'Y' � .... . . . . ,. .. .. �':. . _� . ... . . .
Lender's Name '
CITY � . . TEL NO. S ... �� . .... .. .._. . _ .
lender's Address � '
STATE � IIC. ,I�
I cerlify thot I have�ead this application ond sta�e thal lhe tICEN5EN0. � � �CLnSS -! J - - � ---- �� � � -� -� - � - - . -
obove informotion is co�rect.I agre to comply with oll Coony —
ordina s and S�o�e laws relari g o boilding construction, _. _ , ., ,. .. . ._ . . . _ ,.
�ond ere au�horize represent tiv s of this �ounty to entery , �
upo he ove-mention r or Insp rion pur�iose SEE REVERSE FOR EXPLANATORY LANGUAGE _
C,u-w G; ��
Signmvre of Applt<an�or Ag ni Date - . '.. - . . . .. .. .. . . -. . .
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