HomeMy WebLinkAbout1577A (17) - WORKERS'COMPENSATIONDECIARATiON . APPLICATION FOR PERMIT �
I hereby offirm that I have o cerli(icate of consent to self
insure,or a cer�ifica�e of Workers'Compensaiion i����a��e, HEATING - VENTILATING - AIR CaNDITIONING
ie o thereof(Se<.3800,lob.C.) 76A364C .
.�J7������$b�� l CE.-SIB(REV.10/Bl). . . . ... . . . . .
. P�olicyNo. � CompanyJfn���hULi(�O TNJS. .
Cer�iiied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAfETY
� Certified copy is filed with the tou ly buil ' g inspec- FOR APPLICANT TO FILL IN BURDWG
tion epa ment. - (PRINT OR TYPE ONLY) , ADDRE55 4.N. D�(Q
Dote �Applicont � -�^'� ����TM D.camond &uc �'Q.,
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CER�F EXEMPTION FROM WORKERS' CROS555T. SUI'GtS P� Gi.O6G�I,{1
COMPENSATION INSURANCE
(Thts saAlen naod nof bo complafed if the work Involvsd 6y ABSORPTION UNIT,BTU oisraicr No. vrsoc[sseo av
tha parmif I�for onu hundrad dollars(SI00)or latc.) r �
I certify ihat in Ihe performance of the work for which this � A�R HAN�IING UNIT,CFM U(� �O �
�permit is issoed,I sholl no�employ ony person in any monner gOiLER,BTU � �
� so as to bemme subject to the Workeri Compensation Laws. J nvvapva�s OAiE INSCECTOW'S S�GNATURE
1 COMPRESSOR,BTU I /O v�/ ROUGH ��� �
Dale ' Appliconl �
NOTICE TO APPLICANT: If, aNer making this Certifimte of , VENTILATIONSYSTFM Red.thoo� - � � FINAI �• � C�
� Ezemption, you shauld become subjett to �he Workeri' - . - -
Compensation provisions of the Labor Code,you musl forih• � EVAPORA7IVE COOIER � VALIDATION
with mmply with suth provisions or this permi� shall be � � ,
deemed revoked. � FURNACF. FAV_GRAVItt
� -LICENSED CONTRACTORS DECIARATION F�OOR BTU ' � �
-I hereby offirm thal I om litensed under provizions of Chapter 9 HEAhR: SUSaEN�ED UNiT_ . � � ^� 5'].�]A.
'(commencing with Se[tion 7000)of Division 3 oi 1he Business ' WALL
and Professions Code,and my licenze is in fuli force and eifect. . � �3•• • s •8 O
1 Re rck e
License Number lic.Class '- �'r'u i_ 2 4��Q�� r(�R�f2,rt�.(.i , I • •�1•5� v
� 9� °`
ConfraUar �^Date ' • • •4��b�� V
�❑ I am exempt under Sec. � � � � . 0 Q.�2�$(� . oW,
Plan check fee �n
B.BP.C.for this reason PERMIT ISSUING FEE S (C� Z �
Date: TOTAL FEE I (�
Si9noture �
OWNER-BUIIDER DECUIRATION � � tt.4N CHECK AaMiCnnlT �— � �
I hereby off�rm that I am exempt from the Contrac�or's license �, D � '
law for•Ihe following IP.O50l1(Section 7031.5, Business and NAME � � .
Professions Code): � .
❑ I,as owner of Ihe properfy, or my empioyees wilh A�DRE55 . �
� wages os Iheir so�e compensarion,wili do ine work and ��TY ,,..� TEL NO:
the shucture is not intended or offered for sale(Section � � � �
7044,Business and Professions Code). OWNER �
❑ I,as owner of ihe property,am ezcluzively contracting .{Ob
with licensed contraclo�s�o ronstroct the project(Seo- MA�� - . � �
� tion 7044,Business and Professions CodeJ. ADDRE55 p�d.Box �66568 .
CONSTRUCTION LENDING AGENCY - C�rv O,Hane.I.E2 � 60666 TE�•NO. � - " �"""�'-- . .
I he�eby aifirm thar the�e is a cons��uttion lending agency for ,
Ihe performonce of the wark for whith this pe�mit is issued �OMRACTOR �L �•- - � �
(Sea 3097,Cw.C.). . . . ..' �..:. � .
. . • � ADDRESS tQ9��Q S. L+ n -
lender's Name ' .
e�Tr � Habna Ca. Te�.No. 691-858� _ _ .
Lender's Address
STATE � LIC. .
I tertify�hal I have read this application ond stoie that the LICENSE NO. 3OSSYS -� CLA55 L'-2�� � ��� -� �-�---� -- - ---� �
above Informalion is correct.I ag�ee�o comply with oll Coonty
, ordinances and S�o�e laws relating ro building consrrodion, . . . . .. . _ .- . . . . , ..
and her y authori e representa�ives of this County 10 enter . � .
u on� ,obove- tioned property for insp �io porposes. SEE REVERSE FOR EXPLANATORY IANGUAGE. ._ _ _
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