HomeMy WebLinkAbout1270A WORKERS•�oMPENSAT�aNOE«AaAT�aN APPLICATION FOR PERMIT �
I hereby affrcm that I have o certificate of consenl�o self .
insure,or a certificare of Workeri Compensation Insurance, ���� HEATING - VENTILATING - AIR CONDITIONING
• or o cerufted copy thereo (Sec.3800 ab.C.) � (�_818(REV.IO/81) �
a�Y . /l27 ompony����i . . . , . .
Certified copy iz hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
ertified copy is filed with rhe county building Inspec- FOR APPLICANT TO FILL IN BUILDING �/ C ('� �1..,
lion deporime�l. (7RINT OR NGE ON�Y) ADDRESS 2 � �-/ Ci T�/s �� [A ,
Do1e / �� n APPlitan � LOCnLITY aJ. //�L'� ��
� NO. NPE OF APPIIANCE OR EQUIPMENT � � FEE �-�"��'� �
_ CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �
COMPENSATIONINSURANCE CttOS55T. /�L- F SK /y//r � .
_ (Thls sec}lon need no}be tomplN�d ii fho wark Involwd by ABSORPTION UNIT,BTU DISIRICi NO. PROCESSEO BY
Iha parmH b ior ona hondrad dallers(5100)or leff,) - AIR HANDUNG UNIT,CFM �
I cerlify that in the performance of the work foi which this v ��`O��
permit is issued,I shall nat employ ony person in any manner
so as to become s�bjeU to ihe Warkeri Compensofion Laws. / BOILER,BTU qppRpyqlS DATE INSPFCTOR'S SIGNAttJRE
Date � � APPliconl �
( COMPRESSOR,9TU �� �D � ROUGH �J� �� u��t/
NOTICE TO APPLICANT: If, after making this Certifica�e of VENTIIATION SYSTEM fwAt �� ���
Exemption, you should become subjed to ihe Workers'.
Compensolion provisions of Ihr.Labor Code,yo�m�st forth- � EVAPORATIVE fOOtER VALIDATION �
with tomply with s�th provisions or this permit shall be �
deemed�evOked. � . - � ' � FURNACE: FALI_ V1TY 1 -
� LICENSED CONTRACTORS DECLARATION I FtOOR BN (J '
I hereby offirm fhot I om litensed under provisions of Chopter 9 , SUSPENDED UNIT_ __
��(commencing with Seclion 7000)of Division 3 of the Business HEATER: WAIL �
and Professions Code,ond my licensa is in full force ond effetl.-- /� � - - � �
��.3� C^�. ... a
Litense Number Lia Class - � � � /,� � ^� � V
�L /a .?� 2�QA �
CoNrocio�Date /�-3��9 . ��. . •$ F
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� V
I am exempt under Sec. r— plan thetk fee - � < �4 4,7 5 aW.
8.8P.C.for this reason' � �^
PERMIT ISSUING FEE S • : •4 q 7 5;, �
Dafe:
Signature TOTAL FEE 0 8.3� —�R
OWNER-BUILDER DECLARATION � PIAN CHECK APPUUNT �
I hereby affirm ihat I am exempt from the Controctor's License �
Law lor Ihe following reason(Sedion 7031.5,Business ond NnME ' �
Professions Code): � - . � . .
❑ I, os owner of ihe prape�ty, or my employees with ADDRESS �
woges as ihei�sole compensalion,will do the work and- .
the sfruclure is nol in�ended or offered for sale(Settion CITY TEL.NO. .
7044,Business and Professions CodeJ. �
OWNER �
❑ I,os owner of the properry,am exclusively conlracling
with licensed contmUors to constroct ihe pro�ec��Sec- ���� - `^' -
tion 7044,B�siness and Prviessions Code). a.DORE55 /r d
CONSTRUCiION LENDING AGENCY -� ��Ty �� iEL.iv0. � i`��� . �
1 hereby of(irm�hat there is a tonshoction lending agency for , �
the per(ormonce of�he work(or which thls permit is issued- �� �pNiRnCiOQ � �� - - - -
- (Sec.3097.Civ.C.). ._- .- . _ .. .. . .. . ... . ... _.
. . . __ ADDRESS f/ �� . .. . . . �. � . . . _ . . ..
� lender's Name
_ CITY �� . TEL.NO.�� �� . _ .. . . . .
Lender's Address �
STATE I � IIC. �
I certiiy Ihot I hove read this applicatian and sfale thol the � LICENSE NO. �-1 - CLASS — -- ... . . .. . . _ _ . . . . . .
above informotion is correct.I ag�ee lo tomply with all County
ordinances and 51ate laws relating to building con5lruUion, _ , -
and here6y authorize represen�atives of this Coonty�o enter . ��� - - � ��� -� - -- � �
up the abo� -m,tioned properry for f p,ed�n pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE _ .
l �� �/ .
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