HomeMy WebLinkAbout0975A WORKERS•�aMPENSATroNOE«ARAT�oN � . APPLICATION FOR PERMIT �
I hereby affirm Ihal I hove o cerlifica�e of consent to self .
Inwre,or a certificate o(Workers'Compensation Insurance, ��3�� � HEATING - VENTILATING - AIR CONDITIONING � (�
or a cerfified copy thereof(Sec.3600;ta6.C.) .. � � s ,` /�
ce•e�s�aev.ioiei�
P❑ol'icy No. Company COUNTY OF LOS ANGELES - BUILDING AND SAFETY
Certified copy is hereby furnished.
� Ce�tified copy is filed with the county building inspeo- FOR APPLICANT TO FILL IN sunoiNG m� up
lion deparlment. (PRINT OR NPE ONIY) AD�RESS 1,
Da+e apPltcant •� LOCAL1N / �'�1 Utt!
NO. TYPE OF APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST
COMPENSATION INSURANCE - CROSS 5T.
(Thl�sectlon need nof 6�complafed if 1he work involvod 6y A8SOR7TION UNIT,B7U DISiRKI NO. FROCf55F ar
fh�permil is for one hundrod dollers(f100)or less.)
I cerfify Ihof in ihe performpnce of ihe work fo�whith Ihis AIR HANDLING UNIT,CFM 1� �
permil is iss�ed,I shall nol employ any person in ony manner � gOnER,aTU
50 OS 10 b OT subjec�to tha Worker CO P �10��O AVCRpVALS DAiE INSGECiOQ'S S�GNATVRE
Dafe ppli � COMPRESSOR,BTV ROUGH �� .----�_.�
NOT�C TO APPLICANT: li,_afler oking is Ce�tif,tq� oi VENTILATIONSYSTEM FlNAL
Exemption, you should become subje to the Vyqrkeri
Compensation provisians oi�he labor Code,you mSSf forth- EVAPORA7IVE COOLER VALIDATION
with comply'wfth such pro�isions or Ihis permit shail be
deemed revoked. � �� . FURNACE: FAU__GRAVITY - �
LICENSED CONTRACTORS DECLARATION FLOOR BTU ,
I here6y affirm fhot I am licensed under provisions of Chapler 9 SUSPENDED UNIT_
�(commencing with Section 7000)of Divisian 3 of fhe 6usines3 HEATER: WA��
and Professions Code,and my license is in full force and effecl. \O !'t � � a
lI O
License Number lia Clos ( ,,, h �� �+� �h -O , �
�(") V \ +.J
Coniro Dme�: - - � � . �
F-
�❑ I am ea mpl u er e � O . . . a
Plan check fee
B.BP.C.for this reason� � �
- PERMIT ISSUING FEE S �O � �
Da�e:
5qnorure TOTAL FEE � ��
OWNER-BURDER DECLARATION� PWN CHECK APPUCANT � �
I hereby affirm that I om ezempt from the ContmUor's License D �
Law for the following reason(SeUion 7031.5,Business and NAME -
Professions Code): � � �
❑ I, es owner of Ihe property, or my employees wilh ADDRESS � /
wog?s os�heir sole compe�sa��on,will do the wo�k and
� the s�ructure is not inlended ar offered for sale(Seclian ��TY .SS TE�'NO' �
7044,8usiness ond Professions Code). � � � �
OOWN6R
I,as owner of the property,am exclusively conhocting �0 9 7,S q�-
with licensed toMrattors b construct the projed(Seo Mna - � � � - - . .
- � � tion 7044,B�siness and Professions Code�. ADDRE55 �� � � � �8
CONSTRUCfION LENDING AGENCY �- - cln - � �� - � � TFL.No. ' ' '
I hereby aifirm thal the�e is a cons�ruction lending ogency for � � � • •�j�.Q�
the perFormance of the work for which this permit is issoed � CONTRACfOR -
(Sec.3097,Civ.C.). . / - .. . � . _ • • •���G�c�.,
ADDRE55 � -- - � -� � - � �
tender'z Name 0$� $—8$
GT 7EL NO. �C'/( ] . .. . .. . .. . � . .
lender's Address �
STAIE UC. �
I certify that I have read this applimtion and stofe Ihat�he uCENSE N (�� CLASS � - - - � - - . . ..
above informotion is corrett.I agree to comply wiih all County "
" ordinances ond 51ote laws relotlng building tonstruttion, . ' _ _. _
P y uthor'e repr ntaii of this Coun�y'�lo enler . � � � -��� � � � �
ond hereb - � � '
u an�ove• 'o r for ins Ectio wrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa� e af APPiic or Agen�� L' Dote . . . . . - . . .. ._ .. - "'_'" ... . . . . . . . .
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