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HomeMy WebLinkAbout0693A (4)DECTION WORKERS' COMPENSATION certificate It hereby affirm that I have a cenificare APPLICATION FOR PERMIT of consent to self cafe of corse insure, or a certificate of Workers' Com .nC, r, Ins r nce, or a certifiGQ t Sec. 3800, . C. / 76A354c - HEATING -VENTILATING -AIR CONDITIONING CF - 818 (REV. 10/81) !f'SSf I[/ Policy No o pany Certified copy is hereby furnishe�' COUNTY OF LOS ANGELES 1 • 121.25 oC BUILDING AND SAFETY�� • • 1 21.257 copy Is filed with the county building in pe - FOR APPLICANT TO FILL IN BUIL I T�Certified epar}me (PRINT OR TYPE ONLY) ADDRES / Dole�do pplicant LOCALITY CERTIFICATE OF EXEMPTION ROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST COMPENSATION INSURANCE CROSS ST. (This t•etlon need not be completed if the work Involved by ABSORPTION UNIT, BTU Dnralcr No. vaocE�sro ar the permit h for one hundred dollars ($100) or less.) - certif that in thef f h k f AIR HANDLING UNIT, CFM I y per ormance o l e war or which this permit is issued, I shoal not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ',--rxemption, you should become subject to the Workers' t compensation provisions of the Labor Cade, you must forth- - wdh comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under provisions of Chapter 9 '(commencing with Section 7000) of Division 3 of the Business and Professions Wefullforce nd t.License Number lControl r ❑ 1 am exempt under Sec. 4 BOILER, BTU avvaovats COMPRESSOR, BTU W10 ROUGH VENTILATION SYSTEM FINAL EVAPORATIVE COOLER _ FURNACE; FAU FLOOR BTU HEATER: SUSPENDED UNIT /WAIV � 1 Plan check fee B.BP.C. for this reason Date: Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): �❑ I, as owner of the property, or my employees with wages as their sale compensation, will do !he work and the structure Is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I,os owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree to comply with oil County ordinances and State laws relating to building construction, and hereby outhoriz re retetolives of this County to enter upon the av -m / t e pe ty for inspecti ? ur oses. Signature o pplicant or Agent _ Date ®-- U PERMIT ISSUING FEE $ TOTAL FEE PLAN CHECK APPLICANT NAME ADDRESS CITY - TEL. NO. OWNER�� A A I CITY --7-7, V%/ If /`J TEL. NO. - ..-... . I DATE VALIDATION ;F R's SIGNATURE 7 069.3A p V nta ••••8 d^ 1 • 121.25 • • 1 21.257 H 0.14-86 z i SEE REVERSE FOR EXPLANATORY LANGUAGE Tn Va. ta 'r • t;% f N�r,3z. d O o°nom Z a W n 0 6.. -Z .II ... O > y, K 0` O 7 W. w O_ i�-i £f O m N S 7 n SIS p 0 O p _L O ♦ID_ •' No /o?�?Fo 3 z 'o o w © m yocOw KQro < O S C A� `O -,;A- T.S �.� O ? O u. ^iU,Q'°,. n ?' Q' C. '010 E c 3 O �' lN'7 , N. o o= :9_ 7 A O' o M O .. .. n i n O 0 -o-0 -0 , 45 D O 'p^ , o C+ O j o p Q 3 7. •n Ci =. 3 •' it fa N O O n°: A N p (D O` may w r N n O £ M '3O N S 0 3'w o '[. '4 �� N q .O `'ncxy5-7 3 m �s°o�ao° mf.�-N�0,00 op?.3 ��30 N: 0 010 a �^. o � Vis° m p e w o = Ta so O o o ° . .co 30o.0.N _y aO cp o.cfl O .q n p - d O' -o ";.l 4 "�a_a 3o15...0 Ol-_3 3�a.. //•cO,�° Z. CD N w>,CL. C°c. ro ocz° o to >a ] CD o ..i n• ❑ ca o 3 CL p O w< •;. 3 •' ° O S O- 5 ° O. '^. t0 O O S° T •O to o• N O .�. 7- O. O c0 n O Tri N O' =z i. n •v. n On C O G w O O. CTO N 3 O A j ] 1, ^ = . O7 N Qfl ov's m, too ` ° 0 20 o n p.so a