HomeMy WebLinkAbout1705A WORKERS'COMPENSATION DECLARATION - �
I hereby affirm ihot 1 hove o certi(icafe of con5ent to self APPLICATION FOR PERMIT
insure,ai'a certificata of Workers'Compensation Insurance,
ora.cerrifiedco ythereof(Sec 3800,Lab C.) �en3eec • HEATING - VENTILATING - AIR CONDITIONING
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P❑olity N omponY 1�tQ.7.. .
CertHied copy is hereby furnished. COUNTY OP LOS ANGELES BUILDING AND SAFETY �p�
� CertifieP copy is filed wi�h Ihe tounty building Inspec- - - FOR APPUCANT TO FILL IN - " qDDRE55 ��b bQ✓)')�1/lfj ��l�,�,�L /�
tion e or ment. (PRINT OR TY7E ONLV)
Da1e �� Applimnf � ' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE `�`ITM �'4��'�'�
CER7IFICATE OF EXEMPTION FROM WORKERS' . NEAREST
COMPENSATION INSURANCE . • . CROSS ST.
(Thl�s�eHon ne�d not ba complated tf Ihv work involved by AB�RPT�ON UNIT,BTU DiSfRiCi NO. iRp[ESSED 6Y
1ha parmtt I�For one hundred doltars(f100)or Isss.) � ��
I cerfify lhot in fhe per(ormance of fhe work for which ihis AIR HAN�LING UNIT,�CFM t
permil is iss�ed,I sholl nof employ ony pe�son in any manner
so as�o become sobjett to the Wmkeri Compensotion laws.__ BOnER,BTU AGGRpVqIS o�re INSCECTOR'S SIGNANRE
Dale- npP�i�a�� COMPRESSOR,BTU � ROUGH �b ��/ �'„
NOTICE TO APPIICANT: If, a(fei making fhis Cerli{itofe of VENTIIATION SYSTEM FINAL w'J� v �
Exemptlon, y'ou should become subjecf to the Workers' �
Compensation provisions oi the Lobar Code,you must forlh- �rqppRnTivE COOLER ' VALIDATION � �
with comply with such provisions or Ihis permit shall be
deemed revoked. ' ' FURNACE: FAU_GRAVIN ' '
� - LICENSED CONTRACTORS DECIARATION FLOOR 6iU
I hereby afiirm that I am Ilcensed under provisions of Chapter 9 HEATER: SUSPEN�ED UNIT_
� `(commencing with Sec�ion 7000)of Division 3 of�he Business - `�/A« �
ond Professions Code,and my license is in full force and effecl. � ' !-
License Numbe��S��� Lic.Clas�;U��3�. -'�T�"'p �'Ci �� Q � � O
�r ^ l/ LG. � Iq� , �
ConiraUoQ��p/D��` Dole �—� - . .... . �
v❑ I am exempl unde�Sec. ,. W
Plan check fee
8.8P.C.fo�this reason' uai
Date:
-PERMIT ISSUING FEE S �Q 0 z
Signawre TOTAL FEE
� OWNER-BUILDER�ECIARATION PInN CHECK APPLICANT - •
I hereby aFfirm tha�I om exempt from the ContraUor's License ��
taw ior the iollowing reoson(Secfion 7031.5, 9usiness and N,4h�E � . '
Professions CodeJ: . �
❑ I, os owner of the property, or my employees wilh ADDRE55
...n..nenelhnjrenl<�n�;�ane..ynn �,y�I�.In�tie..,...L.���l " �
the strutture is nor intended or offered for sale(Section C�TV TEt.NO.
7064,Bosiness and Professioris Code). =� '��.5 A
OWNE N� � a N S �L �
❑ I,as owner of ihe property,om exclusively tontrocting �
wlth licensed cororac�ors�o construct the project(Ser DDRESSZ(3O� PA n, �• • • • •&
�ion 7044,Bvsinese and Professions Code). 1 � U �
CONSTRUCTION LENDING AGENCY �iTy•� �n A-rl TEC NO: -� '� � ° •3 9.7 5
I here6y affiim�ho1 there is a consfroctian lending agency for
fhe performonce of ihe work for which ihis permit is issued h�+-�� ' �� . . .. ► ° ' •J�/,7 Jr c�
CONTRACTOR V �
(Sec.3097,Civ.C.)• ...... .. . . . , .
. ADDRE556j � s .v ,t7�✓ . ... �.._.�_. .� � �• b9,20-88 -
Lender'sNome � --� ��-
_ CITY �,t TEL..NO. . . .. . . . ... . .. .. _.
Lender's Address � -� -- - �� ��� -
I cerlif thaf I have read this a lication and stole lhot the SiAT �j ❑C.
Y PP LICENSEN0.,7JS��� . . CLASS� �G'C-.�� - . . . .
obove in rm tion is mrred.I agree lo comply with oll Counly � � � � � - - - � ' ��
ordino es d State laws relotin to 6�ilding construction,
and h reby o�hori r rese � es of this Coonty to emer . . . � ' �� � ��- � - � �-
upon o e- e ' ed ,o rty for inspettion pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE.
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