HomeMy WebLinkAbout1279A WORKERS•�oMPENSAT�oN oE«ARAT�oN � APPLICATION. FOR PERMIT �
I hereby affirm that I have a certificate of consent to self ,
insure,or a certificare of Worke�s'Compensation Insurance, NEATING - VENTILATING - AIR CONDITIONING
'or o cer��f�ed copy�Mereof(Sec.3800, .C.) � 76A364C -
, ,`n CE-818(REV.10/81� �
P❑oI'icy N6l/C.�' Z 7� ompany .. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certi(ied copy is hereby furnished.
erti(ied copy is filed wi�h the munty 6uilding inspec- FOR APPLICANT TO FILL IN BUitDwGn I � /1
tion depart enl. ' ^ (PRINT OR TVPE ONtY) /+�DRESS(�—J yP' � fasr ,!/��
Dote� ��� Applicant ��`��TM # S
� NO. TVPE OF APPLIANCE OR EOUIPMENT � FEE �� � � .
CERTIFICATE OF EXEMPTION FROM WORKER$'. � - NE.4eE57 •
� COMPENSATION INSURANCE CROSSSt. /�/ ��(/�'f GT
(Th(s sacfton naad not ba complatad 1(}ha work Involvad by ' ABSORPTION UNIT,BN pi51RiCT NO. PROCESSED BY
iha permi}is for ona hondrad dollorf(5100)or lass.) � .
I cerlify that�in the performonce of the work for which this AIRHANOLINGUNIT,�CFM /h (�n \O� �
permil is issued,I shall not employ any person in any manner � �J +•\�
so as to become subjed�o�he Workers'Compensafion Laws. BOILER,BTU AGPROVNL$ OATE INSPFCTOR'S SIGNATIIRE
Do1e � Appliconl � COMPRESSOR,BTU `� /� � ROUGH 9 j� �'� �{��y,�;J
NOTICE TO APPLICANT: If, after making ihis Certifim�e of VENTiU1TtON 5Y5TEM FINAL h�S� IOI--�
Exemption, you should become subject to the Workers'._.
� Compensation provisions of the labor Code,you most forth- EVAPORATIVE�OOIER VALIDATION
wilh tomply with such provisions or Ihis permit shall be
deemedrevoked. - � � � � FURNACE: FAU_GRA ItY
�LICENSED CONTRACTORS DECLARATION� FIOOrt BiU
' I hereby affirm Ihot t om licensed under provisions of Chopter9 � HEATER: � SUSPENDED UNIT_ �
'(commencing wi�h Secr�on 7000)of Division 3 of the B�s�ness ' wA«
ond Professlons Code,and my license ii in full force and effeU. . d
(, 3 � � 22 z12Z9A $
, License Number JL��lic.Class�� ,
�- _ �. . . o .g o
. F
Con�mctor �� Dale I ���a 2 5 u
aI am eKempt under Sec. � a
Plan check fee �5 3 2 5� z
B.BP.C.for this reason pERM1T ISSUING FEE S 0 � � �
°O}e: 0 6 3 1—8 8
TOTAL FEE
Signa�ure
� OWNER-BUILDER DECLARATION . rLaN CHECK n7auCnnlT �
I hereby affi�m that I am ezempt(rom ihe Contwc�oi s License - �
Law for the following reason(Set�ion 7031.5,Business and NANtE .
Prolessions Code): �
❑ I,as owner of the property, or my employees with ADDRE55
wages as their sole compensotion,will do Ihe wdrk and
the structure is not iNended or offered for sala(SeUion CIN � TEL.ND.
7044,Business and Professions Code). - .
OWNER �
❑ I,as owner of the property,om exdusively conlrading �
with licensed tonl�odors to construct�he project(Seo- � �`�� �
tion 7044,B�siness ond Professions Code). ADDRE55 /'
CONSTRUCTION LENDING AGENCY �� Ciiv �j����T .NO.�i`� �-�
I hereby offirm lhat there is a construction lending a9ency for ' , ,
fhe performance-of the work for wh2h this permit is issued CONTRACTOR � '"� "�'��
(Sec.3097.Civ.C.). . � . --. . - . .... . .
ADDRESS- ... . -. . . ... �' . - .
lender's Name �7�j(� /'
. . CITY . . C�� TEL NO. /J 7'�/ C� . .. ..___ . _ _ _ .. _ . ..
lender's Address /
I certify Ihvf I have read this applimiion ond s�a�e thol tha pCENSE NO.� � �� ClaSS -l_---� - - ' ..
. . -- - - --..._ . ...._ .. --'
above information is correcr.I agree fo comply with oll Couny
ordinances and State lows relating to b�ilding constiucrion, � .
ond hereby authorize represeMalives of ihis County lo enter ' � � � �- � �� � � ' �
upo he ahove-mentioned prope��y ior�nspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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