HomeMy WebLinkAbout1280A (6) WORKERS'COMPENSATIONDECLARATION APPL'CATION FOR PERMIT �
I hereby oifirm iha�I have a certificate oi consent to seli '
ins�ra,or a certiiicate of Workeri Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
' or a tertifled copy Ihereof(Sec.38D0,Lab.C.) � 76A36eC .
OY�� P 15�� CE-BIB�REV.10/81) ..
Polic ��/�� om ana � � � .
Cer�iiied copy is hereby furnished. COUNTY OF LOS ANGELES BUI�DING AND$AFETY
�Certified topy is filed with the c0unty building inspec- FOR APPLICANT TO FILL IN � � qDDaE55^ �GY Y%�� ��
�ion deparfinent (PRIM OR TYPE ONLY)
� Dafe /��� Applicant LOCALITY ��
N O. T V P E O f A P P I I A N G E O R E O U I P M E N T � � FEE
- CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST
COMPENSATION INSURANCE � CROSS ST. i— �{HI/ll�T
(This s�ttlon nssd nof be completsd IF Ihe work lnvolvad by - /BSOrtvriON UrvIT,BTU oiSrciCT rvo. 7ROCESSED Bv
the permit te for one hundred dollars(5100)or Isss.) AIR HANDtING UNIT,CFM .(�� `
I certify�hal in the performance of the work for which this �O \�`0.\C7�'e
� permit is issued,I shall no1 employ any person in eny manner gOILER,BTU
so as to betome s�bject to the Worke�s'Compensalion laws. nvvaOvn�S DAiE INSFECiOR'S SIGNATURE
�ale upplitaril � COMPRESSOR,9TU � ROUGH 9y3 �
NOTICE TO APPIiCANT: If, after mokfng thfs Certificate of VENTILATION$YSTEM FINAL � �y
Exemption, you should become subject to the Workers'. . "
� Compensation provisions of ihe Labor Code,you musl forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or Ihis permit shall be
deemedfevoked. � . FURNACE FAU TY � �� �
. IICENSED CONTRACTORS DE�LARATION� � v�0oa - aru . �
I hereby affirm Ihot I am licensed under provisions of Chapler 9 HEATER: SUSPENDED UNIT_ �
'(commenting wlth Section 7000)ai Division 3 of the Bosiness � WA« y,
ond Professions Code,ond my Ifcense is in full force/o+nd effect. �S r ZZ �
. license Number `���� Lic.Closs� - . � , V
Controttor�' Dale ��✓�o � "� � - " � `, �A O F� �
❑ I om exempt under Sec. � �� . �• • •8 . d
W
Plan check fee I • •5 a C 5 �n
8.8P.C.for this reason' Z
PERMIT ISSUING FEE S C� � • o�:x 7.'-i�
Date: �
Sgnarure 70TAL FEE . 0 a 3 1—F3 Fi
OWNER-BUIIDER DECLARATION PIAN CHECK APPLICANT .
I here6y aTfi�m thot I om eaemp�from the Conhoctor's License- - . � � .
Law forfie(ollowing reason(Section 7031.5, Business ond NAME - , �
Professions Code): � - .
.❑ I, os ownrr of the property, or my emplayees with /DDRE55
wages os iheir sole compensotion,will do Ihe work ond CITY TEL.NO.
ihe siructure is not iniended or offered for sale(Settion
7044,Business and Professlons CodeJ. OwNER
❑ I,as owner of the property,am exdosively tontraUinB MAIL /J� '
wilh litensed tonlractors to consfr�tt Ihe project(Sec- qDDRESS � � r/�!� �
� tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY ,� f�- L NO. " ��v �
I hereby a{firm that Ihere is a construction lending agency for , �
Ihe performante of 1he work for which this permit is issued � �ONTRACTOR r' � � " �" � "�
_. __ _ _ . . . . . .
(Sec.3097,Civ. .). --
. � ADDRESS �i � .. . . .. .._. . . . .. � .-.-� ..; �:- _ .
Lender's Name �
. GTY _ �r � TEL NO. 3(r�f"� .. . ... . . ..._
Lender's Address
STATE UC, � "7„
I certify Ihat I have read this applicoiion and state that the LICENSE NO. � � CLn55 C� � - � - � --� - - -
above informaiion iz correct.I agree�o mmply with all CouNy , �
ordinances and State laws reloting ro building consfrudion, , , . -_ . _ _. __ . . . .
ond hereby authorize represenrotives of�his County to enter .
upon the above-memioned propeny for inspection porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '
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