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HomeMy WebLinkAbout1397A (13) WORKERS'COMPENSATIONDECLARA710N '� � APPLICATION FOR PERMIT. � I hereby afFrcm thm I have a cerfficate of consen�to self , insure,or a certificate oi Workeri Compensation Insorante) 76A364G HEATING • VENiILATING - AIR CONDITIONING or o certified copy thereof((Sec.3800,lab.C.) - ���Z,�a'��y � CE-818(REV.10/81� - � POolicy o. Ca�ony CpUNTY OF LOS ANGELES�� . BUILDING AND SAFETY � Certified copy ts here6y fumished. � �Certified topy is filed wiih�he county nd�� � SPer FOR APPLICANT TO Flll IN sunowc ���y tion depa��ment. . . ADDRESS �j� �y�n -' �PRINT OR TYPE ONLY) /� Dote��Applicanl LOCALITY `D�mA Y.. 1..�,�F � � NO. ttPE OF APPItANCE OR EOUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' i NEnaEST � � COMPENSATION INSURANCE � � �RO5557. (Thls sadion nsed nof ba tomple}od if}ha work Involred by ABSORPtION UNIT,BTV OIS/RICI NO. PRpCE55ED BY the permif is for one hundred doilars(SI00)or lese.) f� , I certify tha�in fhe performance of�he work far which�his AtR HANDUNG UNIT,CFM � permit is issued,I shall not employ any person in any mannei so as to becoma subjecl fo the Workers'CompensaliOn Laws. BOILER,BTU nPvxOvna oare IN PFCTOR'S GNATURE Date ApplimN � Z� COMPRESSOR,BTU �Q �V �� ROUGH - NOTICE TO APPIICANT: If, affer moking Ihis Cerfifica�e of VENTILATIONSYSTEM � FINAL Exemplion, you should become subject �o the Workers' Compensotion provisions af ihe La6or Code,you must forlh= EypppRATIVE COOtER V�CIDATI N wi�h comply wilh such provisions or ihis pe�mit sholl be , deemed revaked. � . � FURNACE: FAU_GRAVITY . LICENSED CONTRACTORS DECLARATION FLOOR BTU � I hereby affirm that I am licensed under provisions of Chopler 9 HEATER:� SUSPENDED UNIT_ '�(commencing wilh Section 7000)of Division 3 of ihe Business - WALL ond Professions Code,and my I�cense is in foll force and effeU. - � p�, \ Q . License Nomb r Lic.Closs G3� '� � � . . . V -�139,7A ,� Confractor Date 7���S � . . . . � #• • •$ � � V ❑ I am ex Pr onde�5ec. � plan check fee � � � � I • �3�.`5 Q a � B.BP.C.for thts reason- 0 �• • �3 Q 5 0 c=.� Z PERMIT ISSUING FEE S , Date: � -- Signoture � TOTAL FEE �j `� 0�.�.7—8 5 ' OWNER-BUIIDER DECLARATION � PIAN CHECK APGtICANT � � I hereby affirm�hot I om exnmpt from Ihe CoNraUor's License � - Law for the following reoson(Section 7031.5, Business and NAME P�ofessions Code�: . � � , � ❑ 1, os owner of 1he properly, or my employees wilh ADDRE55 � � wages as Iheir soie compensation,will do Ihe work and ��TY 7EL.NO. �he s�rudure is not intended or offered ior sole(Seclion , 7044,Business and Proiessians CodeJ. ' �� ��p 1'_ , � OWNER 4t�0�I. ❑ I,os owner oF the property,om ezclusively contracting �L , wilh licensed contractors�o construct Ihe project(Sec- qDORE55 � lion 704E,Business and Professions Code). � � � CONSTRUCiION LENDING AGENCY ' CITV`� � � TEL.N ' ,��lg - �here6y affirm thot there is a construction lending agency foi , � � the performance of�he work for which this permit is issued COMRACTOR " �' � (Sec.3097,Civ.C.). . .. -. . -.. . . . .. � � nooaess�2Z l fi _ ` lender's Nome ��—O . CIT �� TEL N � Z�`Oo ... .. - . .. . .. - . . . lender's Address STATE �(� ❑C. �y I cerlify Ihol I have reod this applicalion and state ihat Ihe LICENSE NO. TZ�(pI � CLASS � Q�"v - � � �- — �- � above infonno�ion is corred.I agree io comply wi�h all Coony ordinonces ond Siate lows relating lo building conshudion, . � - _. _ _ . . and hereby authori presenta�ivas of this Coonry to enrer � - � . � - � vpon tf obo e-m tio ed properry for inspetrton purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE . . _ � 7 SS" Signot� f Applicant or Agenl Da1e . - ' -' - .. .. ...- .. . .. . .. . . . . ' � _ �S' . • � . .. - +. - �� �l�'f`. �{ • -. ' ;, .. �� . - •1 i� � 5 ; . y `-- . �' ti �;:i: �1 . . �.. `�� . _'', . i�� , .�. i � . __ . � ; �_ ' ' _ � , . � . 4 �_ - - ' �c . , _ . ��. . —' 1 i�✓', ;, ` . ' ^ ' :,` �_t� %\ '! r , . , ' 1 ? , - y ' � ; _ . , - �, l`_ � � .�' �' , . . ° � '; `�' - . � � N � � . . . - . � � - N . . . _ -' � . . ' .� �' ', � % .. . � . �- � r;� ' � , . , 1 . � .�� . . �- . ``. . ' - �--•.� � � � .. r., - �� r � ; , . :f ' `t` � . .. \J'� . c,� ,l ,'y_ t ;t;7 Yr'c. ' � .. • • l' ,,�. t" l.` ni �' �( .�L .+ ;r } '.- . , 0 iJ ,a�{„. ; � i� _ ;� '' i� �'� . 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