HomeMy WebLinkAbout1705A (10) 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
�s--��,6s�s�-������r-n�im,;7�7��E.e,a�RE�.,o,e,, s�rrt
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.
/ _
_. _ . _ _ ._
S�gno�ure o A �or Agenl Da�e - � - � - - - - - �-
• . `,, ' • . .. \ - 1
. . ,` . .� .1 � � ' �i
. /
\ � . .�. , . _ '. .
�`
� ' � . � . •� �' `'.
` ' ;_ . ,
. �, 1 � � \ .. � , __ .
��• . ' ` . 'i ' '' `!� I .. .�
N " ' , �i . ',� . • .
� � � , ' .
� `• � . - . � . . �� • .
� , . � � � .� `� '- • . .
� ` . 1� . . .. .,,
N ' �
, ' '1 .
; ,
� -� i . .
r . .- .,
_ . .. - ,\ -, ' rt,
�'`I � ' . '' � ' . �
, \ • ' tn
• - ' ; � �+
:, . , . N
� . ", . . �
.` � ,`
' �J 'i. ,. .i, , .. , .
' �{5 ' •'i "' - '�. . ✓j �-1' 1 . . .. ,
,� . '�' � , � �; •' .
� ,1t' ' � . ' , , � ..
�
� ' � , •/. ,, _ .. � � ' O p �C �'•?�( .
.�i , . .. , �.
. � , � � N �
. � �:.N f�� c, c � � �' , �
, ' �o oo.N���M� N N(a ' O .
1 ' ' �? 0��." � j O� s?�' O 0 � r^.,� L
� � . '� - 1,, .. ,p 7 � S N-n N Q N O II'� 6.O�^-'S C � N G£ 3 ' �
.. � ', � � � ''. �. � p �L'30 m F.� r:,.�!c a K O��O m o�1 � � .. 7�. .
�r�,a • n � u'_ o;;;n a o r, �, ,_ y3;o �-'
'` , N i o.� �, , ��o a.�-c � A� o o:^'� � ° n -� .. �?o . �
: ?G �T n � � c N 4. �, f� r O<Vc � �.Q � � G ,N CJ ` •G
" � � ' � •t4a�3o
z o ';•,�� Q 3 a � p ,o . -'.o o-'s. N cr 3^.°, r
t9. O o � ^ � f � � ^,o c'� > > �i�� '° �O•° � °^ V N �3 - �
. . � � . �..�° c• m.�' . ° Q o � o m � "�? • r-_p c, o t'n
' . C� O,•p`,N..i SO .� 'O ..`.� _� m e� .Q p„N � n � �,. �p' .
p o -o p � c m '^ o � 0 3 �� � 0 3 a-� ' o, � 3 N � £� �.,�o c'o . x` � -
� �
� �z ' ('1 0 '• o�� o � � f '° s,o °y a� � �.�c; ` . �D x w n N S o =�?� 3: � -
' � � v m�.3 £ � ��,� p n'o�o n,a.a p °,o�'.� o 0 0� p 'D�-o � �
° � o- c, < f _ wo v o o ' q � �o � o -� ��
N -a m 3'
" ,.'�.v o `^ a,�-o o . �, � o- O. v 3 _�< � o . j0 '
, . S . � ' .. o ao �...� �-o o n °a"D v9:-o.p o .�•�- n.� 3 ' �➢
, v, �a- � N°w�o,�o S� o � ���N o,� 3 ��:� oo.o.�-� '_:3 „� �� .
0 0
, o . tP � r-=m o'o n o "4c.� o '.�-s�o?„°�'c °3.:< � �o��°n o o n�.�'•�Z ..
w m o o "fl o o v n-.c o Q n � ;J,�a.Q o a o ° o m � 'o 0
. ` � .. n b oo��, v4 0 � Q ov•n � oaa. � mo a'" � Ma:m -¢� � ; . ,
^ ? p� 'o;�.m °• < oa.�4° ° ..:2�•� � � o o a19 <too, �
_ . . . .. . . V� p'�n n O p�'4 �••-�• � f 5. 0 � 2 '^ �...�U"7 '�" Gl"'^O £,�O ,
!', . � • . . � 'ri Q'�O O � O O�{ O 5 0 D p �m.'L ?O'N p�o t'� O..�� �n ri �tn v
. ' . . .. - � ...N??� � i� W�'30 �� �.�y (1.. � � ;�� �q£�m�j ? 3' �,r/�.i
,` , - . fp O � „�i G ..� �y'� � O O-.fl � � N 7 /
1' � • . . � . ' .- ' . " , ' a'.h 'S N. + � N O•� ' O fD ...� '" /
, � .. � . . . '6 � .�...^N O . 3-7 � CJ � Q n � tl.
� ' ,,. ' . ' � "'O o.Q:G O � � � � i
, '. ,'��. .. _ , . ' ' Q:�� � � O ��Q O S
,.r. . . . y N � �n 7 O.
.,.1 . . ' . . ' . . o o � n
. . . . .. . . ' '//-
, �„/"
/
/ �