HomeMy WebLinkAbout1663A 1664A (9) � �RKERS'COMPENSATIONDECLARATION APPLICATION �OR PERMIT �
.n that I have a certiFicata of consent to self
cerfificate af Workers'Compensafion i�5�,a��e, . �bA3e�c - � .-- HEATING - VENTILATING - AIR CONDITIONING _.�
ed mgy)�rp�f(5�.3800,L b.L.) 6'� �
.�-�,y(,L�7G3)J /�� i� "" CE-818(REV.IO/81� . . .
f-
s° _ Ce�rtified copy is he ebyf umished. - � �� �COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with ihe county building Inspec- / FOR APPLICANT TO FILL IN BUILDING �r� %��1� /��� `
lion deparfinenf. � ADORE55 /�
,y�" (PRINT OR TYPE ONLY)
r Date ��y� Applicanl �'�C-IS f�� � �l /-" LOCALItt �/ .�.,
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE (' /
CERTIFICATE OF EXEMPTION FROM WORKERS' CRO55 ST. )K�n,5 G���`���
- COMPENSATION INSURANCE
(This��clton nead nof 6o complefad i(fha work invalvod by ABSORPTION UNIT,BTU � Di51RKi No. PaOCE55ED Bv
fha permR Is for ona hundrod dollnrs(SI�O)or las�.) � / � . -
I certify thal In Ihe pe�iormance of Ihe work for which Ihis AIR NANDLING UNIT,CFM �
permit Is Issued,I shall nof employ ony person in ony manner - BOILER,BTU
so as to become s�bject to the Workeri Compensalion Laws. / novapvni5 oar[ INSPECTOR'S$ICNATURE
Dote epplicant
� / COMPRESSOR,B7U �/v �^ �7C! ROUGH
P' �'E TO APPUCANT: If, after making Ihis Cerliiicate of VENTIlATION SYSTEM � � FINAt
E. �lion, you sho��d become sub(ecl to the Workers
Compensation provisions of the Labor Code,you mvst forth• EVAPORATIVE COOLER VALIDATION
with comply wiih such pravisions or this permit shall be �
� deemedrevoked. �� • FURNACE: FAV_GRAVITY
LICENSED CONTRACTORS DECIARATION� FLOOR BTU '
- I hereby aHirm that I am licensed under provisions of Chopter 9 SUSPENDED UNIT_ ,
- ��commencing with Section 7000)of Division 3 of Ihe 8usiness HEATER: wa��
and Professions Code,and my Ifcense is in full force and effecL � � � � p},
License Number ���� 5 / Lia Class G�?'� � - , . O
�--- �/-/�i-� � --� o
Conlrodor Da1e � —
F-
❑ �am ezempt under Sec.' �� 6 Q'J A W
Plan check fee 5 0 3/ t'� � ,°,;
B.BP.C.for this rebson pERM1T ISSUING FEE S !� � �� � � � �8 ?
Date: TOTAL FEE � �� � • '7 2 5�
� Signolwe ' � / � .
� O W N E R-B U I L O E R D E C LARATI ON PLAN CHECK APPLICANT �O��/ • • •7 2 5 O c=.+
I here6y affirm Ihat I am exemp�from iha Contractor's license � O 9� Jr_$7
Law for the following reason(Sedion 7031.5, Business and NAME ��i.�.L � 5 �,�.��� �P� ll � �
P�^�essions Codej: � . � -
�L �I, as owner of the properly, or my employees with /+DDRE55 v /, [` 5 r .
� �' woges as th�ir sola comperSaYon,will do�`a work and - • /
the strvctwa is not inrended or offered for sale(Section ��T� �D�y�'f•7/�_ CQ� TE�'N�' Z U��+'V 3 G :'1 6 b 4 A
704l,Business ond Proiessians CodeJ. - � . .
� OWNER VL � I��/�Y� `' �e.• •�`�'2 �
❑ I,as owner of the properly,am exclusively coMracting
wilh licensed coniradors to construct Ihe project(Seo- � �'��
tion 7�44,Business and Profes5ion5 Code�. F.DDRESS� S/�h L J . �3� b Q
CONSTRUCTION LENDING AGENCY ' CITY "��j yl.y,Z�r) � TEL N0. '7 ^�'� � • ° •J�.O O-
I hereby affirm Iho1 fhere is a consfruction lending agenty(or � �
the performante of�he work for which this permit is issued �pNTRnCfOR hQ C���i�L� �tG/ /�/l� 1 , � , ._..__... _0 9,1 5''8�]
(Sec.3097,Civ.C.). c., - . . . _ ..... .. . .
_ � � ADDRESS �I Z f� f ✓"•'•.[ l.�. . . . _. . .. ...- . . - - .
Lender's Name
� CITY ,� ��D�L� TEL.NO.. _ _ ._. _ . .. ..__ . � � . - _ . . _ _ ._ ..
Lender's Add�ess � •
STATE � LIG. g
I te.fify that I have read this application ond sta�a that the � LKENSE NO. � O G 5/ MS5 ���4� � �- � �� ----- -� � - -. - .. ..
obove informolion is carrect.I agree lo comply wifh all Counly .
ordinances and State laws reloting to building construction, � _
ond hereby avihorize representalives of this County to enier- , - � '�
upon the a6ove-ment' ed property for tnspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ ___
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