HomeMy WebLinkAbout1493A (15)WORKERS' CI have ATLON DECLARATION
consn APPLICATION FOR PERMIT
I hereby aflirrn that I have a cartiiicatc of cons.nt to srlf
insure,., or o certificate of Workers' Compensation Insaronce,/nfi1 4C HEATING - VENTILATING - AIR CONDITIONING
or a r.rtified copy thereof (Sec. 3800, Inb. C.)
CE TD8 (RI V. 10!81
Policy No._..- ___ Cornpany_-
Certified copy is heroby furnishud.
Certified copy is filed with the cournly building inspno
tion deportment.
Data__ _..... Appli-nl_
CERT1171CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the work involved by
the permit is for one hundred dollars ($100) or less.)
cerlify that in Ihe. prrfarmarnce of Ihe •.vork for which This
permit is issacd, I shall riot cmplay any person in any manner
so as toobbccc�orrie��subject to the Workers' Compensutt/iio�n Laws.
///,,, JJJ
Date �����l1Appiimnl.
NOTICETO APPLICANT: If, otter making this Certificate of
Exemption, you should become subjecl to the Work—
Compensation provisions of the Lobar Code, you maxi forth-
with comply with such provisions or this permit shall be
cl--d revoked.
LICFNSED CONTRACTORS DECLARATION
hereby nifirm that I um licensed under provisions of Chapter 9
(commencing with Section AM) of Division 3 of tho Business
and Professions Co/de, and my 6conse is in full toren and ellect.
License Nurr,ber.,.y Y�Ik--'�Lic. Class �
Contractor[-g/�QLe-&'ziD&le �{ L}�[/
F1 I am e —a Tul undP.r Sac.____—_,4�J2 —3-1 ar
B.&P.C. for IN. rersson_ .
.—Da Ie:--_-
-----Signe,
OWNLR-BUIIDFR DELI ARAVON
I hereby uflinm that 1 nm oxornp! train the Conlrnr.tor's l it:er�so
Low For Ihe lollu:ving roosan (S -:ion 70315, Business anrd
nP tessions Carlal
I, as r weer of the 1-1-0,, or n'1 y employe as witl
wiages�as Chair sole cornpansalian will do the work onJ
Ihe slruc.t,— ix not intended or ollered for sail. (Socngn
{-� 7044, 0asuuss and Prolessions Code).
LJ I, as nvmer of the property, nm r:xclu—oly cnnlroatiny
with li-ii-d contraclorx to construct Ihe proicd (Ser
tion 7044, Businrss and Nofssions Code.).
CONSTRUCTION LENDING AGFN(.Y
hereby ulli— that there is a construclion lending agency lar
the performance of Ihe work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nnrna -_
I certify Ihe; I have read Ih,s applicolion and *lata that the
aboveinfonra,nou is rorrecl. I agree to comply with oil County
ordinonces and Stale Imus reici ing to building construction,
orad I:ereby authorize reomsentotives of this County la enter
upon he above mlention-1 orope.rly for Inspecliml ourpose..s.
5;gnr. wre r I ApplileW o. (; Dme
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE
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FOR APPLICANT TO FILL IN
BUILDING
ADDRESS '.7�. )••.y �y//_ 'yLLt�
-- (PRINT OR TYFL ONLY)
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LOCAI ITY
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NO.
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IYI'I' Or APPLIANCE OR EOUINWNT
FEE
NIAREST
CROSS ST.
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AB;;•ORI'IION UNIT, RTU—.---
AIR
AIR 11ANDI.ING UNIT, C+M .BO!lfR...-
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CO.MPR(SSOR, BIU.
HNAL
VFNTI LAI ION SYSTEM
FVAP.^.RATNE (.00LER
VALIDATION
FURNACE: FAI.I GRAVIIY_._...
FIOOR
IITAIER. SLISPFNL)ED.. _UNII__
W'ALL
_._
Plan Check fee
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6-0
PERMIT ISSUING FEE $
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TOTAL FEE
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CONTRACTOR
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1CI'NST NO. �,) y';�•'� CLASS (.—•.�'•j,,.i
SEE REVERSE FOR EXPLANATORY LANGUAGE
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