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HomeMy WebLinkAbout1391A (13) WORKERS'COMPENSATION DECLARATION ' � I hereby aiFrm thal I have a cerfificate of�o�,e�,�o=e�f � � . � APPLICATION FOR PERMIT insure,or a certifimte of Workers'Compenso�ion i�5�,a��a, �bA�� . � . HEATING - VENTILATING - AIR CONDITIONING � - or a certified c/opy thereo(f,�,j(SecS.3800,La6.�{C.) � � � ❑ Y �V�..d�,6dRr(S Y I(L P �• .CE-818(REV.IO/81� .- . .. I��3 / ./1�� O� p�_.` Polit No an '+�'� i°Il M I'1�, . - � .lJ. ifi !J Xy"'" Ceriitied copy�s hereby furnished. COUNTY OF l05 ANGELES . BUILD�NG AND SAFETY � Cerlified copy is filed wilh the couMy`6uilding inspeo - - FOR APPLICANT TO FILL IN � BUiLDiNG 1�� � tion deportmenf. ADDRE55 ,n � /j'"�7�J� � (PRINT OR TYPE ONLY) Dale.��PPlitant IOCALIN � f NO. TYPE OF APPLIANCE OR E�UIPMENT FEE � , CERTIPICATE Of EXEMPT N FROM WORKERS' NEAREST tl/u J y7�Am ' �� COMPENSATIO INSURANCE CRO55 ST. !J �l• �!/ (Thtt sott�on naed nol be comple}ad if Ih�work invalred by� ABSOacTiON UNiT,BTU Oi51RICE NO. PRp�E55ED BV ' Tho permlt is for ono hvndrad dollars(f100)or less.) � � � � I cerlify thal in the performance of the'work for which this AIR HANDLING UNIT,CFM /� . ���J permit is issued,I shall nor employ any person in any manner so as�0 6ecome su6�ect to fie Workers'Compe�sotion Lows. BOILER,BTU qppRovnis pAiE INSPEROR'$SIGNATVRE Da�e /+pplicont COMPRESSOR,BTU ROUGH NOTICE TO APPLICANT: Ii, aFler making ihis Certi{icate of VENTIIATION SYSTEM F�NAL �(�' ,�� �:�,,1��.�,.��„�J__. Exemption, you should bemme subjetl ro the Workers' . - Compensaiion provisions of�he Lobor Code,you must(orih- EvqvpRqTNE COO�ER VALIDATION with comply wifh such provisions or:this permit shall be � . � . deemed�evoked. ' - FURNACE: FAU_GRAVITY � � . � � UCENSED CONTRACTORS DECLARATION FLOOR BTU . "1 he�e6y afiirm Ihof I am licensed under provis�ons of Chopter 9 SUSPENDED UNIT_ . HEATER: WA�� �(commencing with Section 7000)of Division 3 of the Business � and Wofessions Code,ond my license is in full forte and effett. � t . A �,�/�N � 5`y � y�� •G� O . Llcensa Number � J� lic.Clas � � - , V Conlratt Date /Lb / . . � -+ � � '' � � O ❑ r I am ez mpt onder Sec. � �� C�/` _ � W Pldn check fee n. � 6.8P.C.ior�his reason- pERM1T ISSUING FEE S �1 3 9.1 A z ate: Signat re ��.m� Ll% �/�f/) TOTAL FEE... � ���� � � �$ NER-BUILDER DECLARATION PLP.N CHECK APVLICANT . .��� �� 9.2 S I hereby affiim thot I om exempt from Ihe CoNrodor's License D � , Law for the(ollowing reason($eclion 7031.5,8usiness ond NAME � � �� • • 1 9,2�5 c=i ProfessionsCode): ' ��� ❑ I, os owner of Ihe properfy, or my employees with AD�RE55 .Q'L O�j+8(j wagcs as thcir solc compen:aticn,will do the wor4 and � � �he struclure is nol intended or offered(or sole(Section Cirv iEl.NO. � . 7044,B�siness and Professions Code). OWNER ❑ I,as owner of the propery,om exclusively con}ratting with licensed contmcrors to consrruct the project(Sec- M�41L � �-�� ' � " � � - fion 7044,8usine5s and Profe55ion5 Code). ADDRE55 CONSTRUCTION LENDING AGENCY � CRV � � �� 'tEt.NO. - -� ��� � I here6y affirm Ihof Ihere is a conslruction lending agency for " the perfo.mance of the work for whlch ihis permit is issued �ONTRACTOR I ��� � ► (Sec.3097.Civ.C.). , - . , ,. ,. . . .- -- - � ADDRE55 � —� - .� . . - . , Lender's Name ' � OTV_. . .. TEL NO. 1 ' Q . . _.. . _ . . ._ Lender's Address � ' S 1 certify ihat I have read this opplicotion and state that�the LCENSE NO. D ��-- --C A55 �� " � � ���'—�� -.. ._. ._._. _. . . . ._. . '� above infamalion is correct.I agree to comply with oll Counfy , � ordinonces�6nd State laws reloting to building construc�ion, - . . an hereby aothorize represen�otives of this County�o enter . - . � . - '� "�- " � � �- �"� -- ' � - u n the above- e lioned ro er for ins eUion oses . - � � , P P �Y� P S E REVERSE FOR EXPLANATORY LANGUAGE , r�m co����.��f�r�-�L> ��uQ.i. � /9�� . _ � SlgnaNre of Applicon�or Agent Do�e � ' I r_: •; � . . r . -' �. .. 1 � , �i .` �1 ` � •,1,,/: ',` v `,.y' �' . � `,1 , . '� 1:- �,., i .. � ,� '� � '^' , � � " ��i' �,'! '��, `';fY . J, �. . t,:: , . , .. v � � + ``,� .t�� �•t • . 'v �.� ' � , i� �, i' ' � . . . . •�• . ..i ,- �i ' .. . Z � , e!(� , ��: �� ..- . , � � . � � ��', � � `, � � ' � , , 70 ' � , , � . . . . , ' Z.O.1 � � ',f. � ��- _. .. - ... v+ '. , ' � � 1 , .----_ ' , ' ' i, '' � _ � , . i - - �: , • � ,, , ' '� ,y. • N , . V� � _ Jr' !� ," � . � ��` ._�. . . �11 � ��• � . . . N � ,'' �/ ! Z . - ` p .�,�.' ',.' 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