HomeMy WebLinkAbout1277A (6) • WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � �
I hereby affkm that I have a certificate of consent�o self
insure,or a certificate of Workers'Compensa�ion�oso�a��e, HEATING - VENTILATING - AIR CONDITIONING
' or o certifled copy thereof(Sec.3800, b.C.) � 76n364C . . �
r ''n CE-818(REV.10/81)
O�y Nd/CX��/ I Company � __. .
Cer�ified topy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy�s filed with the county building inspeo FOR APPLICANT TO FILL IN BUILDIN �, �S, _L r:
tion department. r� � (PRINT OR TVPE ONLV) � ADDRE55 L(/�
� Date��Appiican LOCALITY �. 2
N0. TYPE OF APPt1ANCE OR EOl11PMENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS� NEnRE57 ��
� COMPENSATION INSURANCE � CROSS ST. 'J— (� /
(Thls secfion n��d no}ba complatod(f Iha work involved by ABSORPTION UNIT,BTU OISLRICT NO. �WOCFSSEO BY
the permtT te tor ona hundrod doilars(SI00]or le�s.)
� I certify that in the�performance af tha work for which this A�R HANDLINGUNIT,CFM `v ��\O,n.e
permit is issued,1 sholl not employ any person in any manner gpiiER,B7U
so as to bemme subjeU to the Workers'COffIP2I13011D11 LOw3. / APPROVALS DATE INSGECTOR'S S�GNATURE
Dafe Qpplicont / COMPRESSOR,BTU �/ D ROUGH 9� �
NOTICE TO APPIICANT: If, aiter making this Certi{��Qie of VENTILATION SVSTEM � FINAL y � � Q�
Exemption, you should 6ecome subjed to the Workers'.
Compensarion provisions of the tabor Code,yov must forlh- EVqpORATIVE COOLER VALIDATION
with tomply with such provisions or Ihis permit shall be � .
deemed revoked. J FURNACE: FAU_ RAYITY �
� LICENSED CONTRACTOR$�ECLARATION � I FLOOR e7U J0 U
I here6y offirm that I om litensed under provisions of Chapter 9 HEnTER: SUSPENDED UNiT_
. '(tommencing with Section 7000)of Divisiori 3 af the Businesz ' �`'A« y
ond Professions Code,and my litensa is in full torce and effecL ' J �1 ' O
[/j� !/� �e, ( L
Licensa Number�7"�Lic.Class` `"� , V
�— ,��//� J,�/ :127.7A o
. Controct / """ Dote /^� V . -
❑ I am eRempt onder Set:�- � � � #•' , • • s 8 a
Plan check fee � 1 • •5'a 2 5 �
B.&P.C.(or th�s�eason pERM1T ISSUING FEE s c7 S'�J ?
• • a5a25�
Dore: TOTAL FEE ,,�j'Z
s9�o,�,e 0 E 3 1 —8 8
OWNER-BUILDER DECIARAT�ON PIAN CHECK APPtICANT � �
I hereby affirm thot I am exempt(rom ihe Coniractor's License . � ,
Low foi Ihe following reason(Settion 7031.5,Business ond Nnn4E
Professions Code): � � � � �
❑ I, as owner of Iha property, or my employees wilh
ADDRESS
wages as iheir sole compensotion,will do the work and CITY � TEL.ND.
Ihe structure is not intended or offered for sale(Section "
7044,Business ond Professions Code). � p�yNER
❑ I,os owner of the property,om exdusively toNratting _ MAR �i-'
wilh licenied conlraclors lo constr�ct Ihe project(See- ADDRESS � _`l'`
tion 7044,B�siness and Professions Code). , _
CONSTRUCTION LENDING AGENCY - Cliv TEt.NO. ��v�l�
I hereby effirm�hot there is a conshuttion lending agency for ,
the performante of ihe work iar which this permit is issoed - CON7RnCiOR � � "��
(Sec.3097,Civ.C.). � ' fy�' ,..._ . . . . . • - - -
- - AD�RESS� j _s�C% " . . ._ ._ . ._ . . . : .. . � ..
lender's Nome
.. . CITY ���_ 1EL NO. J'� v . ... . . . . .. .
Lender's Address
STATE �/ IIC.
I certity that�l have read Ihis applicalion and sla�e thot Ihe � LICENSE NO.� �[ CLA55 - � � - - - - - - -- -
above informalion is correct.I agree�o comply with all County
ordinances and Slole laws relating lo building construction, _ . . . . _ . . . . . . _ . . . _ _
and hereby a�lhorize representatives of this Coun�y to enter
o he o ove-mentioned property for inspec�ion purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE _ . _ . .
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