HomeMy WebLinkAbout1490A WORKERS'COMPENSATIONDECLARATION AppLICATION FOR PERMIT �
I he�eby offhm that I have a cer�ifica�e of consent to self
insure,or a cerrificaie of Workeri Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING�� a
or a certified copy Ihereof($ec.3800,Lab.C.) 76A364C � �
CE-BIB(REV.10/Bl) . . . . . . .
P❑olicy No. Campany COUNTY OF LOS ANGELES BUIL�ING AND SAfETY
Cenilled copy ts hereby furnished. . .
� Certified mpy is filed wiih the coumy building�nspeo- FOR APPLICANT TO FILL IN auimiN�. 1,�� Q
tion deporlmenl. ADDRE55 �� JV \U�Qj �1Qi
(PRINT OR TYPE ONLY) ��
Date Applicant ��L�ry , t G �
� N0. TYPE OF APPLIANCE OR EOUIPMENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS� � NEAREST (�,�
COMPENSATION INSURANCE . CROSS ST. . �_ �)\�1ti ti
(Tbls sottlon need not 6e tomploled ff tha work involred by ABSORPTION UNIT,BTU�� DISIRICI NO. FROCESSED BY
the parmit ts for ona hundrad dollars(f100)or lass.) ry � �v � O � �
I tertify Ihot In Ihe per(ormpnce of ihe work for ich Jfii �v AIR HANDLING UNIT,CFM O h/�\\� h
� 1 �L�.�'v�l
permif is issued,1 sholl no�employ pny person in .^ ! gp�tER,BTU
50 OS�O b CO �subject lo ihe Worke ' orppe fi W APiROVAlS UAiE INSPfCTOR'S SIGNATVRE
/� COMPRESSOR,BTU ROUGH � �/�� ��
� Date � � PP�itant ' • .
NOTIC T APPLICAN7: If, ofler mokin fhis Cerffi96re of VEN7ILATION SYSTEM FINAL /Q
�Exemption,�yov should�become subjc+ct to the Workeri
'Compensalion provlslons of the labor Code,you must forih• EVAPORATIVE COOIER VALIDATION .
wi�h tomply with svch provisions or ihis permit shall be
deemed revoked. � FURNACE: FAU_GRAVIN
LICENSED CONTRACTORS DECLARATION � rtoOR. eiu
I hereby af(irm thot I am litensed under provisions of Chapler 9 HEATER: SUSPENDED UN�T_ . �
�'(commencing with Setlion 7000)of�ivision 3 oi�he Bosiness � WAtI
and Professions Code,and my litense is in fvll force and effed. ,� - � a
/� � n L'�-tfNS �( o
Lirense Numbe • �� �/��lic.Class �`� - " -- - ► V
y/� � �
CoMrac' ✓•� Dote �`t'r✓Q � .. O
❑ ' L yJ .. . . V
I am ezempl u de�Sec. a
Plan check fee
8.8P.C.for this reason- �
PERMIT ISSUING FEE S O =
Date:
TOTAL FEE�
Signature
� OWNER-BUIIDER pECIARATION PIhN CHFCK APPtiCANT �
� I hereby aiiirm that I am exempt from the Contractor's License . � z 1 4 9,G A
� Law for the(ollowing reason(Section 703i.5,Business and NAME . . �
P�ofessions Code): �� . .
❑ I, as owner ot ihe property, or my employeez wilh
ADDRESS ��� � ��
- - wo es as Iheir sole com ensatian,will do the work and
thes trutture is not intended or of(ered for sole(Section CITv TEL.NO. � • •�L'��
70E4,Business and Professions Cade). ^„�`' �. Q `� - •� •�2,Q�
OWNER� ��� N F �
❑ I,os owner of 1he properry,am e.dusively confrotling Ma l
_ wilh licensed[onhuctors to consirutl fhe project(Sec- qDDkE55 � �r ) �� 0 9,�9—s 8 _
� fion 7044,Bosiness and Professions CodeJ. � � v '
, CONSiRUCT10N LENDING AGENCY air � � �W Q 7et.No. -- �-,� �-� �-
, I hereby affirm that there is a conshoUion lending ogency for . - ' �
ihe erformance of the work for which this ermit is issued � n ' �� � � '
P P CONTRACIOR��J'/�� ,�^ ��-� � .
(Sec.3097,Civ.C.). C� �- - , � ... . � . -..
. . . . ADORESS �I�� / r)l'�I _ . ._._ . .. . .. _ � . .
lendei s Nama
CIi ��- TEI.NO. J I . _ _._ .. . .. .._
Lender's Address
STAIE / �/ IIC. /7
I certify thal I have read thiz applita�ion ond stare rhat the LICENSE�GO•�� �//)/� - QA55-( � i�� - - -. - - - . -. . . . .
obova informalion is corrett.I agr�ee lo comply wilh oll Coun7y .
ordinances ond Slate low�re fng to building mnstructi6n,
and hereby.outhorize r res t�ives of fhis County to enter � .
-upon��kSov � en' n oderry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
.J ��i
Signai re of� P�ontoi�AgenVr pob � . . . ... . .. -. . . . .... .. �.... . . � .
U �
. . i -.j ...- - \,I ' -. : .'
. . . j ' . . I , ! . .
, � i ' . f. . � � ,
; j �
. � !� , , ' 1 . �. .. .
i i � i , . . _ __..
Z ' � � � � . � , � ' . -. .
� _ . . .
� _ ��" . , ~, . _ ' .
70 .. .. , _ _ _
N , � � , ' -' . , ' . . ,
Z � .� . - ' � � . . ..
� .
N � ' . __. . � " , , . . , � . i: ...
. I � . . . . � i � .. '
. . I ' . . ."', ,
� . � ' ; � , : ..-. �
. : ... .... .' '_'• .'_"_. ' .__^._. ..' . ._. _ _. '. ... . ' _ . ."". - .. __ .. . . - . _ _ ... _
� � � � . i i . , , . � ' ..
� , � ' `
i ' '
. , - -_ _ ' ._ . . .. .. _ . � . .
; I
; i _ . . . _ ' ... ,
) , I � _ .
I,
� i � -
� � � _ � � � - � � .
� " m
. � , �
! �' ' • ' z
' N
. . ' . I , . . . 1 �
, . �
. N
� _ " . i
� � � . �
' _ �� o � o ' �,�, �-O__m Q � F 3' ' o �-o A� ��°5 wo°'� °m� °-0 �a s
, ' , �� RJ ' _.O N !i � 7� � O N n y �. N.� � � ' � �. . � f9
' � " � 9 3 �� 'p�r'v � c'i o o_�o,r- v - ❑in v.�- o o N� �N o m
• • rl . ° 30 �. ,^� A`° �1a�� a'�C-� g^ - ° c�`� o' ^ `�-� � « �
� o � 2 n s f... c 3 0 3 4� a� �o.�t p °-o° '� ' o 0 o p
0 3 nno � e,TN ° o.��.o �. � Wo ° g`. � m-oo'^.,�v° ��'y< � �
' � " O �n -i r N - � �� �'n in' O • �"'�� � ^ 'O'� .�
� . . N o 'n' 0 3 - "'v '' F . o � w 3 �0 3 Z
• s c f. 3 � S �o F 'o � '" A S�o � b o a s„� ._'n' '" ,. o m
m'. a ' r'SbnNH ' o' aom ° 3 �a� ° `� � °b � ° o' o � c ' m 3- � . .
, _ o �: ' ' � ° ° oo °-o Qo°"o�oN ° � � �o `��'� �' .-mo� � o `° � p� .
. . o � mo � � Qo - °`�° F ,'„ ao .� a� T �'� 3bNo° c,'� oNNoo rC-. . .
' ' . ,. � ^ , �o r�c o o-o c� a r� °Tn o a� a �'�.�,;`"nb s� e o f m �
� • �^ �i� m" o ,� c° - '" �vN ° a oo .9'o �'cvo,.^.o� m � -
� a � � ="� - b..y.O O m 10
' . N� K N ,�, c��o'ro Q° s�-a �`.o o,; 3'�.� ,�.� �, 3 0 o D � � .
: . � �-o °-N o'?to �� g ' o' N m" � 3�`:m� o = _. ti a n �, n -
-� o o,0 3 0 0 £ � � <.-• G' ,o « n o �'.
, - � � � 00�.3 °.� O,00 �ao..°aaa '� oo�$'"�. Nb • '
�.f a- � ho ,, . � � ggo � m._ N � �� •av,3 -Di .
n o � � � x o � o F o • �•o'3 3 0 'o 0 0 � m
, •a•, =; -�: ^- �0� 30� o� -i°�.. ^� � � `" 3 -' � m ^ � `0 O
� o m o
- c � °,o�-�. ` �-a�-N a��� � • :m � o a� � o� ° a> > o Z
a _, o �-.^, a N o �
. . . ' ' . c•o o ��.� � ° o 'a� �o o . ;� c° �+o.�� a°3'� vo
. � �;Nn � o� ` m3� � H�.� � .4bn'o.OF �.c � =. s�n
� O � � 7 4�-O O C � � ] N� O N, h S T �J ?'^ �n O
• o' �-� - ao T� a a=� To �-. �