HomeMy WebLinkAbout1286A (6) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affirm thot I have a certiiico�e of consent to self
ins�re,or a cer�ifitaie of Workers'Compensatlon Insuiance, 76A3�� HEATING - VENiIIATING - AIR CONDITIONING
'or a certi ie�oli2 e.p.pf(Sec.3800, _b.C.) � �.ate(acv.toiet)� - � � �
r_
POolicy w� ✓Company - . . COUNTY OF LOS ANGELES . . � BUILDING AND SAFETY '
Cer�ified copy is hereby furnished.
�Cer�ified copy is filed wirh the counry building inspeo- FOR APPLICANT TO FILL IN suuoiNG /y.
I1'on deport nf. ADDRES - �. � [/.
�/ ���,( ,,//�� (7RINT OR.T'PE ONLY)
� Doie r � �a� APPlitant_�`_�„_. �� tOCAliiv �
� �CERTIFICATE OF EXEMPTION FROM WORKERS' NO. NPE OF APPLIANCE OR EOUIPMENT FEE NEAREST
COMPENSATION INSURANCE CRO55 5T. f` (,//iJ/�I� ��
(Thl�secllon naed nof ba completad it tha work lnvolved by ABSORPfION UNIT,BTU DISiRI�I NO. PROCf55E�BY
Iha parmif is for ono hundrad dollan(SIDO)or less.) qIR NANDIING UNIT;CFM� �` Q {`` ` ,e
I cerlify ihaf in ihe perFormance of the work for which fhis � . t�, p�
permit is issued,I shall not employ ony person in any monne�
so as to bemme subjed to�he Workers'Compensotion Laws. BOiLER,BTU APPROVAlS DAIE INSiECTOR'S SIGNRTURE
Da1e �Applicanl � COMPRESSOR,BTU� � �� � UGH g'� �P' � •.
NOTICE TO APPLICANT: If, after making this Cerlificale of VEN71lATION SYS7EM FINAL �� ��
Exemp�ion, you sho�ld 6ecome subject to the Workers'.
�Compen5olion provisions oi the Labor Code,you must forfh- EVAPORATNE COOtER VALIDATION
with comply wilh suth provisions or Ihis permit shall be .
deemedrevokefJ.- ' . '� � FURNACE: FAU_G 6y
� LKENSED CONTRACTORS DECIARATION� FLOOR BTU �
I hereby affirm thol I om licensed under provisions of Chopter 9 SUSPENDED UNIT_
HEATER: WA��
• '(commencing wiih Sec�ion 7000)of Division 3 of the 8usiness
and Professions Code,and my license is in full force ond e{fed. - ` � ^� 7'
/ '�^ 1 L a'
litense Nvmbe��P3�lia Class C..'G4J _ . , O
v
�' �12&bA °C
�coN.oao. � oa�e � �' � � � � #. . . . .g u
❑ I am eKempr under Sec. p�pn check fee a
N
B.BP.C.(or�his reason' Date. PERMIT ISSUING FEE S �/� ,� I ' e�1��O= Z
Signafure TOTAL FEE � � � `��'�"�`'
• OWNER-BUILDER DECLARATION ftAN CHECK APftIfAM � �&3� —�&
I hereby offirm that I am exempt irom the Contracror's license �
Low for-ihc following reason($edion 7031.5, Business and NAME � �
Professions Code): �
❑ I, os owner of Ihe property, or�my employees with ADDRE55 �
wages as their sole tompensotion,will do�he work ond .
the structure is nol intended or offered for sole(Sec�ion CiTY � TFL.NO.
704A,Business and Prafessions Coda).
OWNER
❑ I,as owner af the properry,om exciusively contracting
with licensed coNradors to tonslruct the project(Sec- �"�AR `-
-- tion 7044,Bvsiness ond Professions CodeJ. �
ADDRE55 ��� -
CONSTRUCTION LENDING AGENCY � GRY �- - �,��` EL NO. �/�v
I hereby affirm tha�there is a conshuction lending agenty for ,
the per(ormance of 1he work for which Ihis permil is iseoed CONTRACfOR �� � �
(Sec.3097,Civ.C.). . � (' .- -. . . . . _. . . .. .
- - . . AODRESS /� 1'TI lJ/ ' . ... � ._ . . _ . ._ .. .
Lender's Name
lender'sAddress ��TY �� . . . TEl.NO.� ��/� _ . . „
STATE t LIC. �f 7,
I certify thot I hove read this applicalion and state thot the IICENSE NO. � QASS l�-C-�'. _ ..___ __ .. ._ .. . .
above information is correcl.I ag�ee to tomply with all Coanly �
ordinances ond Stole laws relating to building tonslr�tlion, �
and hereby authorize represeMatives of this Covnty to enter � � � - - � � - � -�- ' - � �
upo abov -me�ttoned property far'n�e�o�urposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
S�gnolure of ApplimM or Agent Do�e - � � " - --- " �
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