HomeMy WebLinkAbout1703A (19) WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR PERIY\IT �
� kereby atihm ihat I have a certificote of consent to self
insore,or a certiiimte•of WorkCrs Compensation i�5��a��e, - HEATING - VENTILATING - AIR CONDITIONING
or a cenified copy rhereof(Sec.3800 Lab.C.) ��'���
�?t(pZyO �i��y� C�� CE-BIBIREV.10/81) I I r
P�ol'�ty N Company �h�V , �
Cenified copy�s hereby fumtshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the tounty buildin �nspeo FOR APPLICANT TO FILL IN eu��oiNc. -t
tion deporimenl. AD�RESS /LQv S�
�( (PRINT OR TYPE ONIY)
,/'Dale �.�, Appliconl i«AUTY ��
NO. 7YPE OF APPl1ANCE OR EQUIPMENT � fEE �
- CERTiFICATE OF EXEMPTION FROM WO RS' - NEnaest
COMPENSATION INSURANCE CROSS ST.
(Thh setfton nasd nol be complvfad if the work fnvolv d by ABSORPTION UNIT,BTU ORiaiCl NO. VRp�E55ED BY
the permlt ls 4or one h�ndred dollars(5100)or lefs.) qIR HANDIING UNIT,CFM /
I certify.thot in the performance of the work for which this (C�
permit is issued,I shall not employ ony person in ony monne�
so as lo betome subject lo Ihe Workers'Compensation Lows. BOILER,BTU APPROVALS pAiE INSGEC70R'S SiGNANRE.
Do1e� epplitpnt - COMPRESSOR,BTU ROUGH �
NOTICE TO APPLICANT: If, o(rer making this�Certilimre of vEMnATION SYSiEM � (� FlNnL `�a
Ezemplion, you should become subject 10�ihe Workeri
Compensation provislons af tha Lo6or Code,yOV mUst fofih- EVAkJRATIVE COOLER VALIDATION
with comply with such provisions or Ihis permit shall be
deemed revoked. � - FURNACE: FAU_GRnVITY .
- LICENSED CONTRACTORS DECIARATION � FLOOR BTU �
I hereby oFfirm that I am licensed under provisions of Chopter 9 SUSPENDED UNIT_
��commencing wifh Section 7000)of Division 3 of ihe Business HFFiTER: WA�� .
ond Professions Code,and my license is in full force ond etfect. � . }
4
License Number �1 S�bS� Lic Class — � � , V
� O
Contraclor Date � - �
F-
❑ I am exempt under Sec. �1 7 0,3 A w
1 Plan check fee Z
B!BP.C.for this reoson pERM1T ISSUING FEE$ � � �• • � e •$ y
Dare: TOTAL FEE � � • � 1 b 5 p
Signature -
� OWNER•BU�LOER DECLARATION PLAN CHECK APPLICAN7 •� •� �S O u .
I hereby offirm that I am e*emp�from the Contractor's License� � 0 9.i 6—8 7
Law for Ihe(ollowing reason(Section 7031.5,B�siness ond Nk7��E � � �
Pro(essions Code): . .
❑ I,as owner of the property, or my employees with � ADDRESS - �
� wages as their sole tompensalion,will do Ihe work and ��TY � TEL NO.
the structure is not imended or offered for sole(SeUion
7044,Business ond Professions Code). . . . py.�NER �,_ \
❑ I,as owner o(�he property,am exclusively contracting � ��L�v t'�i-V�!
wiih licensed contradors to construd�he project(Sec- MAi� � -
tion 7044,Busine55 ond Professions Code). ADDRESS j�
CONSTRUCTION LENDING AGENCY . -- - �iTy J Q - TE�.N�G� A
I hereby effirm thot there is a tonstrottion lending agency for � �"r-� (
the performance af ihe work for whith lhis permit is issued- � COMRAROR � � � �� - , I
(Sec.3097,Civ.C.). y - --
. _ . . ._.._ . ...
'_- AD�RE55 /\ �� - . . . . . ." .. . _.
Lender's Name
CITY . _.TEL NO.� L�b �3 . ..-.. . . . . . . . . . �
lender's Address
STATE ' LIC. - ,
I certity thot I hdve read fhis opplimtion and state fhal the . UCENSE NO.� - CtnSS - --- -- � --�- �
above informa�ion is correct.1 agree�o comply with oll Couniy �
ordinances and Stale laws relating to buitdinq construction, ' .
on reby authori� represemotives of this County to enter � � � � � � �
u n il above-m noned prope ty(or in,f�specr'on purposes. SEE REVERSE FOR EXPLANATORY LANGUACE.
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