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HomeMy WebLinkAbout1704A (10) WORKERS•�oMPENSAT�oNOE«AR�,T�oN � � qpp��CqT�ON FOR PERMIT � I here6y ofiirm fhat I have a cerlificale of consenf to self � insure,or o teriiFico�e of Workers'Compensa�ion Insuronce, or oo-ce�+H�ed copy rhereot�sec.9800,tob:c.) �vnstac HEATING - VENTILATING - AIR CONDITIONING�� �OS� Z�8J-Q65�'�'dl CE-818(REV.70/81) P❑olicyNo. Company� �1���Iy�vTtl�(� , � Certified copy is hereby fomished. COUNTY OF!OS ANGELES BUIlDING AND SAFETY � Cenified mpy is filed with�he coun�y building inspen FOR APP�ICANT 70 FIlL IN qooeESS,}�� �/��}Yjn,�j /f2 �(,.f/ ,wti0 de Imenl. (FRINT OR NPE ONLY) � D01L���qPPli�p�� NO. TYPE OF APPLIAN�E OR EOUIDMENT FEE `«A"rv �CC Glti� I� . CERTIFICATE OF EXEMPTION FROM WORKERS' NfnREST COMPENSATION INSURANCE CRO55 ST. (This sacfton need not 6o complefad if fha work tnvolved 6y ABSORVTION UNIT,BTU OIS14iCi NO. PROCESSEO BY tho permi!ts for one handrod dollors(5100)ar lefe,) AIR HANOLING UNIT,CFM - �O �(����- I tertify thaf in ihe performance of the work for which ihis . �� � permit is issued,I sholl not employ vny person in ony monner BOiIER,BtU so as to become subject to ihe Workers'Compensotion Laws. avvRovais DAiE INSOEC�OR'S bGN4iURE Dote App���a�� � COMPRESSOR,BTU ROUGH �6 � NOTICE TO APPUCANT: IF, afler meking Ihis Certificafe of VENTIIATION SYSTEM FINA[ 0� r�� Ezemption, you should become subject 10 the Workers' �Compensa�ion provis'rons of the Lobor Code,you musf fonh- EVavORATIVE COOLER VALIDATION � �with comply wtlh such provisions or Ihis permil sholl be deemed revOked. � � FURNACE FAU_GRAVITY- . ' . . �LICENSED CONTRACTORS DECIARATION FLOOR . BTU I hereby otfirm thal l om licensed under provisions of Chople�9 HEATER: SUSPENDED UNIT_ � '(commencing with Secrion 7000)of Division 3 of ihe Business ' �'�'A« and Professions Code,and my license is in full force ond effect.- . �. 3/�d3� C7v-�3� `� 10 O a License Number lic Class - - - 0 �y � 1 ' �� V . ContrattorQN�R�U �bt� Dare . . . . .. . � � ❑ I am exemp�under Sec. �—� I� O — W Plan check fee d �B.SP.C.for�his reason�� � , y oore: PERMIT ISSUING FEE$ 1� d ? Signoture TOTAL FEE rj � OWfJER-BUIIDER DECIARATIOtJ - olnN CrfECK APPtKAn1T I Mereby offirm�hat I om exempt from Ihe ContraUoi s License � taw for fhe folfowing reoson(Secrion 7031.5,Business and NAME Professions Code): ' , \ ❑ �, as owner of Ihe prope��y, or my employees wilh ADDRE55 _ . ••, � s es!heir sols ccr^pen�c!ien,wi!1 do!he wo•L�.^.d CITY TEL NO. . �i ?u 4 n ihe s�rucro�e is nof imended o�offered for mle(Setlion � 7044,Business and Professions Code). �• • • • •8 ❑ - OWNER�A � r1 .I,as owner of fhe properly,am eadvsively contracting ^ � ��y 6� �ti l,�' M wirh licensed contractors to construct the project(Sec- � � p � ZU 'V 9 7 v fion 7004,Business and Grolessions Code). DDRE55�-�3O �.v K_ � ' • CONSTRUCTION IENDING AGENCY � � - ��ry� � � � - TEL:NO.� � ' � � �°�3�'7 J�' I hereby aifirm�hol ihere is a conskoction lending agency for . D 9 2�_8 8 1he periormance of ihe work for which Ihis permil is issoed CONTRACTOR (jN�I� �U -,,, ,,� , (Sec.3097,Civ.C.). � / �'� ��/Cl�l' A�DRE55 D �� �C� '^ . .. � . . .. . . . lender's Name .� � . . . . ... ... . . CI7Y �� . TEL NO � 2 / ' .' ._. .. . _. .. � . Lender's Address � . .. . 1 cerlify ihaf 1 hove read this applicafion and srofe that ihe..- IICENSE NO.�- �,,,�� Ra55`20.`��._ _. . .. obove inform ' is corred.I ogree ta comply with oil Counry � ' � ' �'�� � � - ordinonce and S te lows re tin vilding construction, . and her y autho ize repr 'e this Coumy to enler . .. . .. .. .. . .'... ..- . . . - . . . upon 1 , bove- e i n - r inspectio arpos � � ' SEE REVFRSE FOR EXPLANA70RY LANGUAGE • �'✓ � d Sfgnmore of Applico Ayenl Daie � . . . ---- � . . . .. - . .... . . . ... _. . . .. ; -- - - . _._.._ �..I.._ . _...` , 1 � � ' ; , � i' , ii , , , ' i , . i ; N . . . � . � . . . i ._ . i T � . ,'{ .;Ii ` .. 0 • ..I "' I . !' ; .. 7p . .. . � , � � . . . .. ... . N ,i. .Q., . 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