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HomeMy WebLinkAbout1320A (13) WORKERS'('OMPENSATION�FCLARATInN APPLICATION FOR PERMIT � I hr:r�by nffirm �ha�I have a ceriificafe of consr.ni �o sell ' • ���sii�P,�.�����cr�«t�or w��k��s'c:o�}��ioi�s��iio��i�,5���.����, n,b�. HEATING - VENTILATING • A!R COWDITIONING or a certdicd<opy�he,rof(Sec:!8(Al,loo.C.� cF nln(kev.iuiai) P❑ollcy No..._.._..__Company_.__._. CerRfiad copy is hnrr,by furnished COUNTY OF LOS ANGELES BUILDING AND SAPETY � Certilied copy is filed wiih ihr.counry buildiny���spe�� FOR APPLICANT 70 FILL IN B11°°'":' ?j�+ .5�. {�fAIY��.� ��(r, liOn:l2pnr�rnr��l. (H41;J7(Yi I'�Pi(1N.Y; /�I;I)R!Si_.. ._ _ _' '_" "_'_'_'"_ a�i�—....-- --°'�r,u�„���_— — --... ..�...� --- �ocn���v OA1 R��F Of- G/}SlflLR � NQ IVPf OI AFFffANCE OR 1'C7UIPMkNi ne ----....—..—..--.--...—..—.---- CERTIFICATE OF EXEMPTION I�ROMlNORKfRS' � �..—��-.--�.--._.— .--._._ .. -._ NLi14Eti1 COMPENSATION INSURANCE ���h�15`��� (This section need nof be complefod iF fhe work involvvA by _ ��f15QNPilON UNii_R�li__,_.__ crh�i::�r:r; reorissro���� � i.� Iho permit is For one hundred dollars(5700)or less.) I tr.riify thni in ihe porfor�na�,ce o1 ihn AIN IIANDLING UNIi.CF.11____,._.___ . .wurk for whi<h i6is ��-----..——..—_..—....— --� �� Lti-L� permil is issucd,I shull nol employ any peison in nny mnnncr _.—__....._'—.—._. ._..C—_._—..' so ns lo bncorne subject to iho Workeri Coaipnnsnlion Lnws. . _ I6OIIfR,UEU�.�._.�.—'-- .... .... n���,�uov;��u r,nu r�t��vrcu.;u:i:�c�r�.oruui . .__—.--.. -�—,.—. ��"L�.._...—. —.._—.. .—' —.... z�a���3 �rc.? . Dc�lc—...—_—Applic�ini_._'_ � (:UMI'NE55nR.£�TU__' r ._ . I� k(;!I:;H . ......._�_..�._._—.._.—.. _. '—'—''—_ '' '_' "_--' N071CF TO APPLIC:ANi: If, aftnr rnnkinq fhis CeiLficuln ol ��I�ili/�TI(.),VSYSIE,�q IINAL ��/� � �—" 6xenip�ion, you shoufd bewme sabjed io the V✓o.kers' . . ...--..--.----..._. ._..__._.—_-. -- ..—...-- --ft._ ...--�—�—'- Compansniion p�o�ii�o��s of the I.�bo�Code,yo�i ir usf forlh- �VAPORAIIVF(_UOLER VALIDATION with comply wiih surh provisions or this pr.rmii sh�ill bn _ _.... .. .,_ � c�een�Pc�rc��kec�. FIIRNACE: �IAIJ,_CiRAVITS'__ LICENSLDCONTNAC.'10RSDFCLARAFION ii.002 ____.,_i3ru.,._____,,.,,,— �— --......—..._—. ._. .---.—..... ----��-- I hcr�liy aff�rm Ifiu�I<�rn IicenScA iirdc!�p+ovisinns of C:ficyN�:r 9 HtAfER: SUtiFI'�I)ED__.__UNiI_.__ (commen<inq wilh Seclivn 7000)of Divixion 3 nf fhe Businesx _, � , '�'�•���--_�`_- � oad Professions Co;le,ond iriy liranse rt;in full lorce nnd offecl. � �� - � � ._ ..—.. . .. �_. -� �':� -- , � �., —...— " i ;;�.0 A A Z8 3�3,3� G�Z� e��� .._ —..—....----...---- �� „ LI<PPS@ Nuniber_'__:_'I.ic.CI<rns__ � , � � �� ` ���c'yY%[�e ��•.. Z'_jS' ) —.—_ —.. —.._—._—..—_... _... ,i ,- Q ; Conkniior=�' . Ucrte__� _ ^ V ,;�'))l� �iG�— ,_i. � � � � —__—.—..---- _—.._ I am cxen,pi under SPc...__,.___._,_ plan check fee '� '� �'c��':)L ii � .�..—..---..._—. —...—_._.—.... . � R.&P.0 or I iis reason---..— -- � I PERMIT ISSUING FE�E �� � r�t)r;�,...;:��� -----..—.,—o��t::_.—_ -------- ------- TOTAL FEE O S v � Siyriot:ire_...—..—--_—'.—_— OWNER fiU4UER UFCIARAIION ��i.���aai:x ni,�ucnn�i � I h�+rFi�y affirm iLui I nm exempt irom ihr.Contracror's Licenw —�- �--�-.—... —..--�-- �aw for rl:a following reuson �Se�uon 70J1.5, Bu�incss rinci wa:�� ,�]yfj'IfN S R&�rR���'�x,�ret��v-,�L' HEA't � �iessinnn Cr.de•1: /�—___._—.___--_'_ I. C�c fxvner ot II�C proF+,R.Iy, ur my fniploye.es v:illl ADDRf55(.j/i�� /��U��y[�,'S /Q't/'(�' 7I waqes as fhair sole compennaiion.will du ihr:viork nn�l —'--�--�-- --...---��--�--� 6 � 1 Ihe slrucfiire is nc�f in!�ritied or oiter�d for talc;Sacfi�n C:ITY v����J(,s iFl.NGI�(p��4`�.+L�' I /OG�,FSUSIl1p55 00.)P!O{(?SSIORS Codcl. ----"—'---'-- o.v�vra��_.��, �(�• Co • ❑ I,c�s owne�u`the propnr!y,nin exciusively coniractiny wifh licensr�d cnnlrnctors 7u con.r!rucl liie proje�cl(Soo- AdAIL f�z� �S��N:SET d�t.vn- tion 70AA,13un�mnsx and Proiessions Codn). ADDGffiS'� ._..__.._..__..._.. CONSIRUCTION CENDINC AGENCY CiTV�,�, 9U,G��,� TR h'Orj)��,��41j�/ I hareby affinri Ihat thero is n constniUion lendinq agency for ► Ilir,performprir.r ol i6r,wnrk for which this permii is issued <.pNIRACTOk ��/V.S �,�7�'���(7 ' (S�c.30)7,Civ.C.). � —------.. ��/�2 �y . ...—_..—__.—... PDf)HE:�r� F.:lj'��`�'Cl.�'�,�1 7��J�) _ r.nccrs arne—_..—_...—__..--_... ,/ _'_'_--'_"_"—___ .—.. Clfl' .{ � /�/ 1IL.NC)y/ /� ) U/`� /VL�.1 O � 7 1'"GZ�� Lr.ndcr'sAddress.___._ tilA7� �-,{ p .—.. IiC.-^ -...--..—`- I cerii(y thrn I hrnr.reod ihis nPPli�:u�iun iind sFotr:1ha1 Iltr: LICI.NSE NO�ri• z�'3�cZl,� CLA55�+'2v•••G'�� obovc infonria�ion is rorrcct.I uyrec io mmply wiin nll County Cf1J111CIIlCPS und Stnle!crv:s relaiiuy to buildinc�construc!ion, nnd hereby nidhonec rnpresenlntivr.x oi ihis Coun�y io anter upon�lie ab �•o�ri nrionv�l��r� rt�fcr inspr.ction pu�posr:s. SEE REVERSE FOR EXPLANATORY LANGUAGE __��,� ..� _y .�>Z �) ���— s�y u�r;��o�d n�:nr�o���o•n�;,,,v n;��o : . � 1 ' . . � ��� �� ��, `� !, �� �. 1 � �. � '� '� � '� � � ' . . �� � � � �, . �� �. � � i 1� ' . � �. ' � ' �+� . � :z �, i `�'� � i '� .f ' '�t � f � 1 1 •Nt " � `� 1 � �Z • � � � '., i0 t .'1 i` i i� �� �i � SI ,� , , 1 1 ! ', i1 ,.1 1 1 � � ; , . �. � 11 � , ; , ' �. ''� , �' � , � ' � ! 1. 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