HomeMy WebLinkAbout1271A (6) WORKERS'COMPENSATION DECLARATION �
I here6y aifhm that I have a tertiFicale of consent to self APPLICATION� FOR PERMIT
insure,or a certifiwie of Workers'Compensoron Insurante, HEATING - VENTILATING - AIR CONDITIONING
'or a cerlified copy Ihereof(Sec.3800, b.C.) 76A364C � .
���/����/ -CE-B18(REV.10�91) - -
POolicy�IL(d'L��ompony 12�. . . . � . .. _ . �
Certified topy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
riified topy is filed with tha coonty building inspec- FOR APPLICANT TO FILL IN BUu��N� )'L c J.� �.
lion depart en. C� ADDRESS �R �� r G /
(DRINT OR NVE ONLY) ��� , �
Daie � � Applicant� LOCnuT
NO. TYPE OF APPIIANCE OR EOUIPMENT- FEE
CERTIFICAiE OF EXEMPTION FROM WORKERS NEnREST '
COMPENSATION INSURANCE CROSS Si. r !1/Y1/j/[T
(Thts iaclton naed nof be complsled It the work(nvolved by ABSORP710N UNI7,BTU �ISiRICI NO. ' PROCESSED BY .
fhe permi�is for ono hundred dollan(5100)or less.) �1 O
I certify that in the performance-of the work for which Ihis AIR HANDLING UNIT,CFM I /�(� 0.` O� �
permit is issved,I shall not employ any person in any monner �' � , \ \
so as to become subject to the Workers'Compensalion Laws. BOILER,BTU APPROVALS �FIE INSPECTOR'S SIGNATURE
- COMPRESSOR,BTU Q ROUGH J� � ��`�
Date � Applicant
NOTICE TO APPIICANi: If, after moking this Certifimte of VENTitATiON SYSTEM FiNAI 2�!�
Eaemption, you should become svbjett to the Workers'
Compensation provisions of t6e lobor Code,you mu5f IOrth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.- � � FURNACE: . FAV_G � .
� LICENSED CONTRACTORS OECLARATION FtOOR BTU O I
I hereby affirm ihaf I am licensed under p�ovisions of Chopler 9 SUSPENOED UNIT_
HEATER: WA��
- '(commencing with Section 7000�af Division 3 of the Business r
and Professions C1ode,and my license is in full force and effect. _I �� - y O
License Number�.lcy��lic.Class�"� - - . V
,�Lt.Ll� fftS/ � , �1 2 7,1 A �
Conlrado �_Dale �
1�
� I am exempl onder Sec. � -� � �}� o i • •8 uVi
Plan check fee N
8.6P.C.ior this reason PERMIT ISSUING FEE S D � • •4 9.7 5 Z
Dale:
5qnoture TOTAL FEE • • �4 9.7 5�
� � OWNER-BU�LDER DECLARATION . MnN CNECK AaPIICANT . , O�3� -S H
I hereby offirm Ihol I pm exempt from the Contmctoi s license � �
Law for the following reason(Section 7031.5,Business and NAME
Professions Code): � - � � � �
❑ I, as owner of ihe p�oper�y, or my employees with ADDRE55 -
wages as the'v sole compenso�ion,will do the work dnd
the structure is not intended or offered for sole(Section Ciiv TEL.r70.
7044,6osinen ond Professions CodeJ. .
OWNER
❑ I,as owner of ihe property,am exclusively conlraUing
with licensed coNractors to conshuct Ihe projed(Sec- N'Aa
ADDRESS � (�
tion 7044;Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY - � pn � �� TE�.' o. �v� �
I hereby aftirm that the�e is a consrrvction lending ogency fo� ,
the performance of Ihe work for which this pe�mH is issued �� � GONiRAGTOR �
(Sec.3097,Civ.C.�. - . . � . . . ... . .
. . ADDRE55� p v . . .-.... . .
lender's Name
Lender's Address � � CITY . ffL NO. '7� �� . . ._ _ . . . . _
I certif that I have reod this a lication and sta�e�hol�he SiAie � /' r/ LiC. _ .
y pp LICENSENO.r �(�Y CLA55 � � �� � � ..
a6ove iniormation is correcl.I agree fo tomply wilh oll County
ordinances and Slafe laws relaling to b�ilding constrottion, � , . _ _ .
and hereby authorize represeMatives of this Coun�y to eNer - � � - � - � " �
upo he abo R-m�nfioned proper�y for inspecnon purposes. SEE REVERSE FOR E7(PLANATORY LANGUAGE ,
/� �
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