HomeMy WebLinkAbout1602A (15) � - WORKERS•eornaeNSAnoNoeanRAnoN � - APPLICATION FOR PERMIT `
. 1 here6y ofiirm thot 1 have a certificate oi consenf fo self �
insu�e,or a certificate oi Wo�kers'Compensation i�:��a��e, HEATING = VENiILATING - AIR CONDITIONING
ar�_y�p� copy thereof(Set.3800 b.C.) � � 76.436aC . .... . . . .. . . . . .
��q�, ie{aev.ioieij
. POol�t NaZ�Company � � �
Cer�ified copy is hereby turnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the couMy 6uilding inspeo- - FOR APPLICANT TO FILL IN - - � BUuoiNG �,� ro
lion deparfinenl. (PRINT OR TYPE ONLY) ADDRESS
Dale Applicdnt� — lOG4UTV
NO. TVPE OF APPLIANCE OR EOU�PMENT- FEE
CERTIFICA7E OF EXEMPTION FROM WORKERS' NEAREST , �
COMPENSATION INSURANCE � CROSSS7.�
(Thf�s�eHen naod not be eomplalad if Iha work Involved by ABSORPTiON UNIT,BiU OISiRi��NO. VROCESSCD BY '
the parmi!i�for ona hondrad dollen(SI00)or laf�.) pIR HANDLING UNIT,CFM /(� •
I cerlify Ihat in the performance of the work for which this .
permit is issued,I shall not employ any person in ony manner BOIIER,BiU
so as to become s�bjeU to ihe Workers'Compensolion laws. nvvRpvaiS OATE M FCfOR'S SIGNANRE
Dofe� an��•T7���S'� �OMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, o{ler moking this Certifitote of VENTIIATION SVSTEM FINA�
Exemplion, you should become s�bject to fhe Workers'
� Compensarion p�ovisions of the Lobor Code,you must forth- EVAPORATIVE COOLER 8 � V/� ID/+T� 1� ,
with mmply wiih such provisions or ihis permit sholl 6e -
deemed revoked. - ' �� - FURNACE: FAU_GRAVI7Y
UCENSE�CONTRACTORS DECLARATION � Fi00R eiU
I hereby offirm thal I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
'(commencing wilh Section 7000)of Division 3 of the Business ' �''A« - ' � - ' �
ond Professions Code,ond my license is in full force and e(tecf: + '� , . . � � a
3'���Ci � S � o .
- License Number lit.Class�_� - ► � V
Controctor Q�� Date I�a—�-� � - � � . �i b Q 2 A O
� I am ezempf under$et. #• • • • •a V
Plan check fee /2 -L� 'I • •5 6 0 0 �n
B.&P.C.for this reason� � a
PERMIT ISSUING FEE S o Q • • •5 b O O� Z
Date: TOTAL FEE SIo �
5gnature 0 Z 2 3—8 5
� � OWNER-BUIIDER DECLARATION � PLAN CHECK APPLiG4NT - � -
I he�eby affirm that I om ezempt from the Contractoi s License �
law for ihe following reason(Section 7031.5,8usiness and N�4ME
Pro(essions Code�: � -
❑ I, as owner of the property, or my employees with ADDRE55 ���L� _ n,� .
weges as iheir sole compensatian,will do the work and
Ihe shucture Is no�Intended or oTfered for sale(Sec�ion Cltt �� TEL.NO. .cJ
70d4,Business and Professions COde). - OWNER ^\�
❑ I,os owner of�he p�operty,am e•clusively coniracting MA` � " � �
wifh licensed conlracfors fo c0�slrucl the project(Sec- qDDRESS �
iion 7044,Business and Professions Code). �
CONSTRUCTION IENDING AGENCY . �iiy ��,p�p, � � - �
I hereby ofiirm ihat ihere is a conslrucfion lending ogenty fOr - . ,
ihe periormance of ihe work for whith this permit is iss�ed �ONTRACTOR " " " � �
(Sec.3097.Civ.C.). . . . .
,
ADDRESS . _ .._. ._._.. . ' . . . . ' _ . . .
Lender's Name �
. . CITY TEI.NO. . . - . . . . .
lender's Address � �
I tertify thot I have read this opplimtion and stote thot�he SiniE LiC.
LICENSF NO. - CLASS - � �� -��� � � - -- - � -
o6ove informotion is correct.I agree fo comply wirh all County
ordinonces and SIa1e laws reloling to building consiruclion, . _ _ _ . . , _ , . . . _ __ . _ -
and y authorize representotives of this Caunty to enler � . �
u n rh above-men ned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� ����- '���3� _ _ .. . _ _ _
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