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Home My WebLink About0428A (4)WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self Law for the following reason (Section 7031.5, Business and NAME insure, or a certificate of Workers' Compensation Insurance, . HEATING - VENTILATING - AIR CONDITIONING dr a certified copy thereof (Sec. 3600, ab. C.), _ 76A364C wages as their sole compensation,will do the work and CITY �,'i1 r Company CE-818(REV. 10/81) 7044, Business and Professions Code). - Polity Certified copy is hereby furnished. .. COUNTY OF LOS ANGELES with licensed contractors to construct the project (Sec- BUILDING AND SAFETY .—f;2ft—Certifled copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING CITY- T tion depa{(rI iint. (PRINT OR TYPE ONLY) ADDRESS CONTRACTOR �— Dole Applicant LOCALITY 6,' / L —r CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST ft COMPENSATION INSURANCE STATE LICENSE NO. CROSS ST. u� (This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED E the permit Is far one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM I certify. that in the performance of the work for which this permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers' Compensation Laws._ APPROVALS DATE INSPECTOR'S SIGNATURE --TICE TO APPLICANT: If, after making this Certificate of nptlon, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 '(commencing with Section 7000) of Division 3 of the Business and Professions Code, andel my license is in full force and effect. License Number ` c/ Lit. Class �•��-`-� Contractor Date !! ❑ I am exempt under Sec. B.BP.C. for this reason COMPRESSOR, BTU Q O OUGH VENTILATION SYSTEM FINAL 7/ le7 EVAPORATIVE COOLER VALIDATION FURNACE: FAU_GRA T FLOOR BTU HEATER: SUSPENDED UNIT_ Plan check fee Signature OWNER -BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): - - - -- I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY the structure is not intended or offered for sale (Section 7044, Business and Professions Code). - • ❑ I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAR ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY - CITY- I hereby affirm That There is a construction lending agency for the performance of the work for which this permit is issued - CONTRACTOR �— (Sec. 3097, Civ. C.). - ADDRESS Lender's Name w CITY 4,0 t Lender's Address I certify that I have read this application and state that the STATE LICENSE NO. above information is correct. I agree to comply with oll County ordinances and State laws relating io building construction, . and hereby authorize representatives of this County to enter TEL. NO. -% 7" 7 a .... . .... .... LIC. 7 u the a ove-mentioned property for in Oct 'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE In- ignature -of or Agent Dote 01 } a '0428A U ad #j.,,•..8 O (• •53.25 LU N • e e5325Q= Z Ga02-88 PERMIT ISSUING FEE $ TOTAL FEE 152.75 TEL. NO. 019LI V. NOW, TEL. NO. -% 7" 7 a .... . .... .... LIC. 7 u the a ove-mentioned property for in Oct 'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE In- ignature -of or Agent Dote 01 } a '0428A U ad #j.,,•..8 O (• •53.25 LU N • e e5325Q= Z Ga02-88 rm �I us rn r .•1 c ,W 0 m- - • C�Q. p J• Y -30 D O N❑ N O N- On ] �. ~O '^ A°i. O © • =r tr p O Q° uo °'V' £~O OoW r• N 0. C: p�._�,�3S. .o S ,� D W a a i n °D.o-4. -� 7O N n N _ -v �—o3 Nw f°°m 0-0x .. ? 3 r T'O C N S D. C p. O~ O O ]; S 'O °- 7 'O C ,O •'• O f m n' °" O O a �, Q D .< u .O ° ° 0 ' O w f1 N ]- ^ C ] D L7 - N n•N'p c o.3 TSD a ID o Q:. o N ° 7 D' �" O 7 OQ'O.Q •°° ° :O 17 17' a �" o poa-0 rc m _ f v N Nn•ro m•ca7�.o;N £ �3.<�.� o�o qz o o:� oK. ¢ p a ov 3 0 0= N o o.m "co nO p p-o C O Oa D na 3< n a o N f p CTO ° �nm° cn �c a-o_p» .��?. CLS O a0