HomeMy WebLinkAbout1284A WORKERS•�oMPENSAT�oNOE��RAT�oN . qppLICATION FOR PERMIT �
I hereby af!'rrm tha�I have o tertificafe of conseM to self . -
inwre,or a certifimte of Workers'Compensation Insurance, �bq36aC HEATING - VENTILATING • AIR CONDITIONING
'or a cer�t'�fi�ed/Jcopy ihere f($ec.38D0 Lab.C.) �E-918(REV.10/Bl)�
p❑olity N6"'�' � 2� ompon !7 ... . . .. , .�.... .
Certified copy is he�eby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
yI�'7I�Cenified copy is f�led wt�h iha munty building inspeo- FOR APPLICANT TO FILL IN euimiN�
/— JtioJn deparf ent. (PRINT OR TYPE ONLY� ADDRESS � �� � �
Date�AppilcaM ` . LOCnI�tt - 'L �
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFIUTE OF EXEMPTION FROM WORKERS' � �-- NEAREST /] � • �
COMPENSATION INSURANCE ' CROSS 5T. /2(/LS(d—� HI/Lf!��/ �
(Thi�saciton naad nof be completed ff the work Involved by ABSORPTION UNIT,BTU DiSfRICT NO. PROCESSfD BY
ths permlf t�for ona hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of�he work for which this � O �Q`O� .Q
-permit is issued,I shall not employ any person in any manner
so as�o become subjeU�o ihe Workers'Compensalion Laws. BOILER,BTU pppQpyq�S DAfE INSPECTOR'S SIGNATURE
Do1e Applicant � COMPRESSOR,BTU � vD� � ROUGH �� � �u�,.;�
NOTICE TO APPLICANT: If, afler moking this Cerfificare of VENTIIATION SYSTEM FINAL 3 S� �,v
Exemption, you should becorrie wbject to the Workers' ..
Compensation provisions of the lobor Code,you must forth- EVAeORAtive COO�eR VALIDATION
wi�h comply with such provisions or ihis permit shall be
deemed revoked. � � � FURNACE: FAU_ W !�
� LICENSED CONTRACTORS OECLARATION � � FLOOR BTU V
I hereby aifirm thot I am licensed vnder provisions of Chopter 9 � SUSPENDED UNIT_
HEATER: Wq��
�'(commencing with Section 70D0)af Division 3 of the Business � }
and Professions Code,and my litense is in full force ond eFfecl. � a
��— 5 Q � �� 2��l l� 0
Litense Number tic Class� - - � � � , . V
i' � � �o. • e •H OC
" ! O
Contrattor Date � - - �
I • •51,5p ''
❑ 1 am exempl unde�$ac. - - _ .. . uVj �
� • Plan check fee • e.5 1,5 0� uai �
B.BP.C.for fhis reason� � . Z �
PERMIT ISSUING FEE S 0 8 3 1 —8 3
Dafe:
5ignawre TOTAL FEE
OWNER-BUILDER DECLARATION PIAN CHECK APPLI�?.NT -
I hereby offirm thot I om exempt From Ihe Conirador's License _ �
law far the following reoson(Section 7031.5, Business ond NAME �
Professions Code): - - � � �
❑ I, as owner of the property, or my employees wilh AD�RE55
- wages as their sole mmpensailon,will do the work and . -
Ihe slrutlu�e is not inlended or offered for saie(Section Cliv TEL.NO.
70G4,6usiness ond Proiessions Code). .
OWNER �
❑ I,as owner of the properly,am extlusively tontratting
with licensed contractors m construct the projed(Sec- �`'�A��
fion 7044,8usiness and Professions Code). - AD�RE55 /l
CONSTRl1CTI0N LEN�ING AGENCY Citt � �^_ i�.NO S���Av�
I hereby oifirm that ihere is a consiruttion lending ogency for ,
Ihe performonce of the work for which Ihis permil is issued GONTRACTOR � �-� - � -
(Sec.3097,Civ.C.). . .._. _.. . . --
- � � ADDRE55 - -�- � . � � � _ ..
lender's Name
� - CITY. . . TEL N0..7 �' _ .. ._ . . . _ . .
lender's Address �
I certif that I have read ihis a limlion ond stale�ha�iha. STnTE L uC. �7�
y PP LICENSE NO. � CLA55- "�(_.QJ
. . ... ... . .. ... ' .__....... . ...
abave iniormalion is correcl.I agree to[omply wi�h all County �
ordinances and Stote laws reloting to building constrottion, ' '
and hereby ao�horize represento�ives of this County io enter � � �� ��� - - �� ��" �� - "- - �
vpon rhe obov -meQ�ioned properiy for ins'p�ecrion purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
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