HomeMy WebLinkAbout1576A (17) WORKERS'COMPENSATIONDECIARATION , APPLICATION FOR PERMIT �
I hereby affkm�ha�I have o cenifitate of tonsent to self .
insure,or a certiiicate of Workers'C pensation Insurance, ,bA3a�c HEATING - VENTILATING - AIR CONDITIONING [S
o ertified copy there�a[f�{Sec.3800 La6.C.) �.818(REV.10/BI)�
Pol� No��. �'��r�'Co�ny .
Certifled topy is here6y furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY
� Certiiied copy is filed wiih the county 6uilding inspec- FOR APPLICANT TO FILL IN - BunoiNG •
tion deporlmenL (PRINT OR TYPE ONLY)_ A�DRE55
Dale�Appli� ��s}Z�d� tOCAIi Y Q
N0. NPE OF APPIIANCE OR EDUIPMENT FEE "
CERTIFICATE OF EXEMPTION FROM WORKERS' NEaREST
COMPENSATION INSURANCE CROSS ST.
� (Thls section naed not ba�omplatad if}ha work Involved by ABSORPTION UNIT,BTU DISTRICi NO. FROCESSEO 9Y
1he permH i�(or ona hundrad dollars(f100)or lecs.) qIR HANDLING UNIT,CFM �� , �I`-r
I ce�tify thal in Ihe performance af ihe wark for which this
permi�is issued,I shall not employ any person in any mann�r -
- so as to become subject to ihe Workers'Compensalion laws. BOIIER,6TU AFVROVAl3 �ATE INSP Ci0R5 SIGNATURE
Date opplicant COMPRESSOR.BTU ROUGH ' �I�.,��,�. }a�. ) '
NOTICE TO APPLICANT: I(, otier moking rhis Ce�rflmre of VEMILATION SYSTEM ' FINAL � (��,�
E:emption, you should becoma subject to ihe Workers' .
Compensation pro'visions of the labor Code,you mus�forth- �/qppRATIVE COOLER VALIDATION
with comply with such provisions or �his permtt sholl be .
deemed revoked. � ' FURNACE: FAII_GRAVItY � � -
� � tICENSED CONTRACTORS DECLARATION � FLODR BTU
- I hereby of(irm tha�I am licensed under provisions oi Chap�er 9 SUSVENDED UNiT_ �
HEATER: WA�� � .
'(cammenting with Seaion 7000)o(Division 3 of the,Bosiness � }
ond Professions Coda, nd my license is in full force and effeU. � �p_,p '� . � r.l . y
w �W \l� 0
litense Number Lia Class�-+LD �� � , U
���C�o ,c aG.�� vt� o
Date� :'1 5 7�6 A u
❑ I am ezempt under Sec. " , .._ w
• Plan check fee �i• • •• �8 a
8.8P.C.!or this reason� . �
PERMIT ISSUING FEE S �0 I • 1 1 `a 0 0 =
Dale:
S�gnature TOTAL FEE �'a � � r�Q O�
OWNER-BUILDER DECIARATION MAN CHECK APPLICnNT �
I hereby offirm Ihat I am exempt from the Conrrador's License � a��2—8 6
taw for the following reason(Section 7031.5,Bosiness and NAME ��' - -
Professions Code�: � � � . , . -
❑ I,as owner of the property, or my employees with AD�RESS � ,
� � wages as lheir sole compensalion,will do the work and CITY TEt.NO. �
the structure is nol intended or oifered for sale(Sectivn ''�a-
7044,Business and Pro(essions Code). � . - � --
OWNER
. ❑ I,os ownei of the properiy,am exclusively toniracting MA i -_ _ ._ .
wilh licensed ConlroC10r5�o conslruct ihe project(Se[• qDORF55 �
tion 7044,Business and Professions Code). . '
� CONSTRUCTION IENDING AGENCY CiTV EL.NO. " � ---
I hereby affirm that there is a construction lending agency for '
Ihe per(ormonte af the wark ior which this permit is issued CONTRAC � � � ►
(Sec.3097,Civ.C.). � . .. . . . . - .. . .
� ADDRESS ���� � � " � . . .
� Lender's Nome � �
� . CIT TEL NO. ���ZGI i .... .. . " - - - -
lender's Address �
I certif Ihot I have reod Ihiz a licotion and state that Ihe STnte tIC.
y pp � LICENSE NO. - - �-CLASS��1/(' —� � � .- -. �. .�- _- - . .
obove infor ion is correct.I agree ro comply with oll Coonty -
ordinanc a Staie lows relating to boilding construdion, . . . _ .. _ ,
and h b uthorize representatives of this County to enler . - � - -�- ��� � " ��
0 ove-me uoned pro .rty for inspedion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. _
ignarure o(A limn or Agem Date � . .- . . . .. . ... .. . _ . . . . .
:-;
_ � -,
��� _, •'�� ; � s.v� i
-- ,
' ._. _" ,' `':` ' ' i. 'J'� , .
�.�
, - : ' , , : � t �, 4 `��
' y} s %
:, : • ;:i ' ":
. , :�e r,y �` _.
i �:.
' � \l � '�
. _ _ . � .
� . , �r;,r i�, t . ,. ,
. � . " , .. ••t f� 1'f ' , .. a.
� � � -- , ' . � .r� ,' ' `.. .
�p � -• . � l' i.� (,\ j C� .
Z � . � , . . . '� �i ., 1.:� ' .. . . .
� . ' � * t ' � '
� � ~� ��� ' .
. , . ., ,
, . ; � �
� ! _ _ -;; -;:,. _ - _ . . .
, � _ .. .. - - , - . ,
_ .. _
.
r r �� - .
Y.S ', �` � ... . " . . , '
�.t. ` � % . ,.
r ., � 1'� . !. .1 ,� . •
, 1 r ✓!/ ,. ' . ,' �
� . 'r' , �
' ��� �: .i '� . ' . � ` _t' . "q
I � v �� ` !. (�a i . , •� � • 0
� "� A
Ll � l. t � , .. N
' � ' +� +.. �+ . ' Q
. �: , � '�- � .�
_ � s i' {%1
� �:• �• . �'i I '1 . ' .
w ✓
� r r-. .
} � _ .�• ,�'�� `�1.;��'• , .f� .. -' - � �
.J,,r �' . � ^�J 'j rl, ' i ' _
I�' L� '�! `: , ( � � ,}i ,
� � `� a t .r �V" . ' . . '
� rM�: . ..
� �i �`" . - �� ,
.. ,
. _ . , � %'. r_-
.. • � .. ' .. , � -_ � !p/O n.P I+ 7 .
� �� � ' � �-n y� N..n 3 m =',�'�j �i . .
• _"r ''" _ o � � f o�c�i °���"�' �, =«.m c c � c.
. . . . � , -- . ' M � �'in p��-. o'f� ° _' vi^ N ° ��,s ° o - o.N N 't . .
. � -. �c �-NI� „ �� Q,? o ��-�,- o� ❑Noa,�,'��aoo fl ? � e'i �
f.�� � ' � � � Q T� 71�,, C cCJTG �.A��in� 'KOy� :Stl"�'6 .4 .. � .
� o .. fN 3 n Q'�"w LI • cr� a • '� �.c u. o �N o v.� o Y, Z
.'! , . . � � � � , ?'O c ��� £ ! G,c 3 � 3 ON-u �p .n.. v�.��O .r N'O M' p O . i�it .
� > O Q> Y. . O ' q � rJ C ,�.`. _. G ' O'n _ii..,.�. G. �p
,�^ . (l. K .p N . Q O'7 O -^O r N u O 2T"'ri�n 9 �,�N�=p .
'. . • . . C -' �S ro � � � �c.
.j�
� . v' oNo �' N -�o3 ' N �� ' � � an oU �:°OnN '•'- �'oao - �'C
�., ,. o. � o ��_f v £ i^ °< 3 fl-in • o � m n •e--mto�� o N o o�.,� .
� N .3 f o N � o =o n. 2� o. 5 a a o a:,o N 3 O
� . � � rSoo:"'1a� p < f � ao � a,� � ��''t?�� � �v,�� co�`c %:.;.,�
n �
' - - ' . ' . . > � N��!(�.'�' O C � N -� N O 'O a ���.� W n N s� �.�� lD� C�
� � - N � , o�... _,s o 0 o fl-� 7 '=3:°,n o� ' • '° 3""� r*i
fl ', � �� o:ro?..�. �c; � m �v.N o.°U °° v_._v � a q °Z.��..� Cr1
, . .. U_ A . . q 7 O p"�7' r" (T O �T3 (� � D p ✓_� q 7 A -^�' Y"
7 � O �Zy �'y.� 'D C 7 ;�� (D:�o''O 3 � � j-G O�" "' _ < �'
"`,";' . . . ' , � ' f^ mv +� o�� � n-6z�'> > ;� .03 � m .o �'" ^_ � °�": A
;� .. . - � O'?Y.eY� NQ��TIGKO � N �{ O '� � CJ�N m — � < 3er� D . ..
.,,,'',• • • ,roo'��_o`� � on.�� > >.oa.� sc oo.Nov �•000 ,.�s` � �
, �c=i,�'no ° ovoao4� �° 0 �'�`o.� H3 ° u � _`csor� n�� Z
' � ry O�A U 3 N O n �� 4 F 7 '4 ...n 7 � c� N t0•�p C � O �''.
`l I• ' . � � ?� Q x � � � S 3 7'� -�O l�! c..V+ � Q.7 � O'��� m� , -�^�4
-- . � � . � . . � � °-n �1�:;�,c Q ta b Q,�Q�,o�n f ,�:'3- � �'�3 N n.N 3�i W° �'•
. . 1-. N �" o C N O O rJ tn p� �C 0,�,^ p U y � .
. , � � Q.'5. T <' Y-. -� o mv o , F '� o �..�A £ fl �^ Uo �.
`'-..� i, . !� . � " , ' ' �_ c,��':�fy,C �S7 �m -C� O' t'' ��?a.NSmmo s-
/ . �, ����n n T.@� O n-7'O O T,c n n- n- �
� /� . . � . � _ ^ � � n ' �tJ ..�-_�--�'��_r
, � �� . . '. . o � " .
•^�.'�,� . . . . �_�---"
''�� i � . - '" ��_____"_,_,..-
, ;' ( '-J--��`'
`��f-�_