HomeMy WebLinkAbout1285A (6) WORKERs�oMPENSAT�oNOE«ARAT�oN � APPLICATION FOR PERMIT � I
I he�eby offhm that I hvve a certifica�e of tonsenl to self �
insure,or a certificate of Workers'Compensorion Insurdnce, - - HEATING - VENTILATING - AIR CONDITIONING
' or a cer ifi d capy thereof(Sec.3800, b.C.) �dA36aC � .
CE-818(REV.10/8I�
POolicy � 2?� mpany �� COUNTY OF l05 ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with ihe county building inspec- FOR APPLICANT TO FILL IN eunD�NG [' ��.
tion deparfm nt. . � ADDRESS �L' c• �Q.� U♦
�` � (PRINT OR TYPE ONLY� L
Date �l APPlicant �""�� LOCAUiYm/}�yZt^7 2
N0. TYPF OF APMIANCE OR EOU�PMENT FEE v ivn .7
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /f�/
� COMPENSATION INSURANCE� CRO55 ST. /,l �S�C�f/I�/'JGICLC
(Thl�s�cflon n�ad not b�eomplN�d if the work lnvolred by� ABSORP710N UNIT,BTU� oisrcici No. vaoc[ssco ar
fh�perm�t b for ons hundnd dollors(5100)or less.) � !'� �
I[effify iha�in the performance of the work for which this A�R HANDLING UNIT,[FM �J
pe�mil is issued,I shatl not employ any person in ony manner a d n '�
��so as to becoma subject lo�he Workeri Compensation Lows. 60ItER,BTU APPROVALS DATE MSKCT04'S S�GNATVRE
Date /+pplicanl COMPRESSOR,BTU c � � ROUGH 3 �"� ����✓
NOTICE TO APPLiCANT: If, af�er making this Certi(ica�e of VENTiWTiON SYSTEM FINAL
E.emption, you should bemme su6ject to �he Workeri. �
Compensotian provisions of ihe Labor Code,you m�st forth• EVAPORATIVE COOIFR VALIDATION
wilh comply wilh such pravisions or this permit shall 6e
deemed revoked. - � . FURNACE: FAU G T /O
- LICENSED CONTRACTORS DECLARATION � FLOOR BTU " �
I hereby affirm fhat I am licensed under provisions of Chopfer 9 HEATER: SUSPENDED UNIT_
'(commencing wilh Section 7000)of Division 3 of�he B�siness ' WA��
and Profess�ons Code,ond my I�cense is in fvll force and effecf. � �^� 2 Q 5 A y
/�,� 1 � 2 p
licensa Number 4 Y Lic.Class� - ► �e e • � •$ V
Contmcror Date
/� (�� . . . - � • •J�.jn 0
V
❑ I dm eaempt under Sec. . s o y 5�,��� a
Plcn check fee
B.BP.C.fo�fhis reason� y
PERMIT ISSUING FEE S- �� 0&3 1 —8 II ?
Date:
S�gnarure TOTAL FEE
� OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT . .
I hereby off��m�hai I am exempl irom the Cont�actor's license�� - � . �
Law for the follawing reason(5ection 7031.5,Business and NAME . .
Professions CodeJ: � � �
❑ I, as owner of ihe properfy, or my employees with aDDRE55
woges os their sole compensaiion,will do the wo�k and CITY TFt.NO.
the s1r�tlure is not in�ended or offered far sole(Section
7044,Bosiness and Professlons Code). � ' .
OWNER
❑ I,as owner of the property,am exclusively tontratting _
with licensed contraclors�o constroct the projett(Seo- MaR
- tion 7044,Business ond Professions Code}. �
ADDRESS � �/�
CONSTRUCTION IENDING AGENCY - CITY J�_ L NO. 'a'��
I hereby affirm tha�there is a construclion lending agency for ,
ihe performance of�he work for which this permit is issued -� CONTRnROR -�- � � �
(Sec.3097,Civ.C.). � - � — - - ., �� � � �
noouess � � ' •
Lender's Name
. CITY TEL.NO. ��C�— .... . ... _. , . . . _..
Lender's Address
I certif that I have read this o plicalion and s�ate that the STA7E� ( � p' LIC. '�`
y p IICENSE NO. `(�( CLASS- C�G.� �- -� -�-- �
above information is correcl.I ogree to comply wilh all Coonty -
ordinances and State laws relating to building constroction, � _ .
and hereby aothorite representa�ives of this Coonly to enter , � �
�p n tha ob ve-menrioned properry for inspec�ion purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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