HomeMy WebLinkAbout1134A (5) WORKERS'COMPENSATION DECIARATION � ' �
� I hereby affkm�hat I have a certifitote of consent to s�- l APPLICATION FOR PERMIT �
Insure,or o certificata vf Workers'Compensation Insuran � 76A��,c HEATING - VENTILATING - AIR CONDITIONING
or a certiiied copy thereof(Set.3800,La6.C.) , �
� CE•8�B(REV.10/81)
a�yN�PE 601293�omPa�y 2enith Zns. LA County Un; nco~p.•
Cer��fled copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
aCertified copy�s filed wit the eo nt Iding s FOR APPLICANT TO FILL IN eunoiNc
non depor+ment Geo �ra `�.��• �'���• , ADORE55 2�73$ Earlgate
1Z�15^p6 (PRINT OR TYPE ONLYJ ,
Date �� APPiim LOULIN �.ralnut � .
- NO. NPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NenReST
�� COMPENSATION INSURANCE � � CRO55 ST. T,eIDOSI & Brea Canyon Rd:
(Thls secllon n�ad not be eompl�}ed if tho wark Involvad 6y ABSORPTION UNIT,9TU p151R1�f NO.� PRp�F55 v
Ihe permtl i�For ane hvndred dollars(5100)or lass.) AiR HANDLiNG UNIT,CFM� i � �
I certify thai in�ha performance of ihe work for which this- 1��
permit is issved,I shall nat employ any person in ony manner �
so as to become subjetl ro the Workers'Campensation Laws. �. BOitER,eTU I piCROVAlS OAif INSCECTOR'S SIGNATURE
Dote Applicont COMPRESSOR,6TU ROUGH �
NOTICE TO APPUCANT; If, afrer making this Cerlificate af VENTIIATION SYSTEM FlNAL �
Exemprion, yo� should become subject ro the Workers'
Compensation provisions of the Lobor Code,you m�st forlh- EVA70RATivE[OO�ER VALIDATION
with comply with such provisions or this pe�mit shall be � .
deemed revoked. � FURNACE: iAU AV 7 - i �
LICENSED CONTRACTORS DECIARAT10N � 1 FLOOR —BTU�...��. lO 00 . �
I hereby affirm thot I am licensed�nder provisions of Chapter 9 SUSPENDEo UNii_ i
HEATER: WA��
'(commencing with Section 7000)of Division 3 of the B�siness � }
and Professions Code,and my license is in full force and effect. a
License Number 441678 � i;�.eiass C 2� . � . . . ► V .
Conrmuor xeating pa�e 1z—i5-86 °G
❑ O
I om exempt�nder Sea "�l 1�.(� w
Plan check fee #� � d
B.BP.C.for this reason' � ' '�
PERMIT ISSUING FEE S 10 �0 I • •2 Q 5 O ?
Date:
TOTAL FEE 20 50 . o •2 Q 5 0 u
Signature � � .
OWNER-BUILDER DECLARATION � mAN GHECK ava�iCaNT - _ I 2� 7—S d
� I hereby offirm that�am exempt from the CoNraclor's�icense � .
Law for the following reoson(Sec�ion 7031.5, Business and NAME �
P�ofessions Code): /
❑ �, os owner of fhe properfy, or my empioyees wifh ADDRE55 � � \
� wages as their sole tompensalion,will do ihe work and T�
tha snuclure is not intended or offered for sole�Seclion �ITY TEI.NO. v
7044,Buslness and 7ro{essions Code).
OWNER t�g��� S�ear ( Shear �
❑ I,as owner of the property,om exdusively contratting MAi` ^�
with licensed confrac�o�s to conshvcl the projett(Sec- ADDRE55 20738 E`arlgate� � 'oU
' tion 704E,Business and Professions Code). / I .
CONSiRUCTION IENDING AGENCY . �iTy - � � � � EL NO. ]�4— �F— 0110 �
I hereby offirm thot there is a construction lending ogenty for t`falnut 7 �59 3 , / �✓
�he periormonce oi the work for which this permit is issued COMRACTORGeO Bra2i1 Pl t C� `..
(Sec.3097,Civ.G). / . ..
ADDRE55.].'lI}ZO SO. Broadway � � � �-- : �'� ' _ . ' • .
Lender's Name � -
an Gardena� . Tei.No.515-040 • _
lender's Address �
STATE � LIC. ,
I certify�hal I have reod this applicotion and stola Ihol fhe� LICENSE NO. 4�}],6 H - CtASS C 20.... � .. - .. � . . _ . ' �
above informolion is correct.I ogree to comply with all County '
oidinances ond S�ote laws relating�o building cons�ruction,
and hereby auihorize representotives of this Counry�o enter . � ��� � �� � � � � �
on e abo�e•men�ioned p�operty!or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ .
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