HomeMy WebLinkAbout1278A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � �
I here6y affirm ihat I have a certificate ol consenl to self
(nsure,or a certificate of Workers'Compensarion Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
� or a cern,R�e'�d ncopy ihereof(Sec.3800,La6:C.)♦ CE-818(REV.10/BI)
Polity�Je�'���1 ompany�� ��� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hereby fumished. . .
Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
1'on department � /1 ADORESS ZY g � �
�' �� �PRINT OR TYPE ONLY).
Da1e��Applitanl N . LOCaIIT � �
N0. iYPE OF APPLIANCE OR EQUIPMENT . � FEE �[�
CERTIFICATE OF EXEMPTION FROM WORKERS' � CROSSSST. /j,l �UK✓k/R l T��`
COMPENSATION INSURANCE
(This tattion naad not be eomplalad if Ihe work Involred by ABSORPTION UNIT,BTU DiSiRiCE NO. PROCESSED BY
fhs perm�l�s For ona hundrad dollort(5100)or less.) . � D
I certif thaf in the erfo�mance of Ihe work for which this AIR HANDLING UNIT,CFM
permit is issued,I sholl no�emptoy ony person in ony monnei 0.����
so as�o become subjecf to the Workeri Compen5afion Laws. BOILER,BTU APPROVALS DATE INSGECTORS SIGNANRE
Dafe ApPlicont . I roMPRESSOR.BTU ��D0� � � ROUGH 9 �� � �u�
NOTICE TO APPIICANT: If, af�er making this Certi(itare of VENTRATiON SYSTEM FiNAI �—�Y
Exemptlon, you should become subjett to the Workeri
Compensa�ion provisions of the labor Coda,you must forth- EvqppaqrlvE COOtE2 VALIDATION
with comply with such provisions or this permit sholl be ' ,
deemed revoked. � FURNACE: FAU—GRAVITY� j 0
- LICENSED CONTRACTORS DECLARATION FLOOR BTu �
I hereby effirm that I om licensed under provisions of Chapter 9 HEATFR: $USPEN�ED uNiT_ �
'(tommenting with Settion 7000)of Division 3 0(Ihe Business WA« }
and Professions Code,and my Ircense is in full forc���e...and effecL �� Z Z H A o.
License Number I�r Y�lic.Closs�� � � � �• � • • •$ V
�
Connacror � oate/I- -fr9 I • •5 3 2 5 �
❑ v
I om e.empt under Sec. • • •J�3?5 u a
B.Br.C.fo��ti�s reoson Plan check fee
PERMIT ISSUING FEE S � � 0&3 1 —8 8 �
Daie:
S�gnat�re TOTAL FEE 3 7 j
OWNER-BUILDER DECLARATION � PLAN CNECK A7auCANT .
I hereby affirm that l am exempt irom the ConlroUor's License - �
Law for ihe following reason(Section 7031.5,Business and NAME .
� --Professions Code): - � � � � �
❑ I, as owner o{Ihe property, or my employees with ADD7E55
, oges os their sole compensation,will do the work ond� CITY TEI.NO.
Ihe slrottore is not imended ar aifered for sale(Section �
7044,Business and ProFessions Code). . � � ,
OWNER
❑ I,az owner oi the properfy,am exclusively contracting �L
with licensed comracfors�o conslruU the project(Sec- �
lio�70dd,Business and Profe55iOn5 Code). � AODRE55 ��
CONSTRUCTION LENDING AGENCY � �� CIN f� - EL NO. - �i -
I he�eby affirm that there is a�mnstruction lending ogenty for
ihe performonce of�he work for which this permit is issaed - �pNTRACfOR � - -- - ,
(Sea 3097.Civ.C.J. I , . .. .-. . . .
. . ADDRESS � ��� J - - ' .. '- . . . .
Lender's Nome �/7/'�l� �1�
. . CITY TEL NO./.J r `�S Y� . . . ._. . ... . .. __... _ ..
lender's Address
STATE ' � /��i ! .UC. /`� . _,
I certify that I have read Ihis applimtion and s�ote tho�the LICENSE NO. —{d / CLa55 C.� - - .-
._ ._ .... . __ -. . . . ..
above in(ormation is correU.I ogree to comply with all Counly
ordinances and S�ote laws reloting to building mnsiruction, - �
and he�eby aothorize rep�esenta�ives of�his County to eMer , - - � � �
�p Ihe obo - entioned property for'nspec�ion purpos s. �
"� /� n � SEE REVERSE FOR EXPLANATORY LANGUAGE _ .
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