HomeMy WebLinkAbout0692A (4) WORKERS'COMPENSATION�ECIARATION APPLICATION FOR PERMIT �� ��!_J �
�''F-hereb`y affirm that I have a certificate of consen�fo self -
��5��e,o�a� rti(imte oi Workers'Com nsafion i�s„� �e, HEATING - VENTILATING • AIR CONDITIO ING
. or a certi(ie y� f(e.3800, .C. � 76n364C �
/ /� �C -BI8(REV.-10/81)- . . . - - .. � '/-
�Policy No. L P Y �� ( � ���/(,/"
CertHied copy is hereby furnish . COUNTY OF LOS ANGELES BUILDING A�S ETY
Certified mpy Is filed with the co nt bui m in pe- � FOR APPLICANT TO FILL IN - Bu��oiN
tio[�/{/y 1m (PRINT OR TYPE ONLY) P.D�RES
Date d"i� APPlicant- � LOCnIiTv � � �
NO. NPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEaRFST
' COMPENSATION INSURANCE - CQO55 5T.
(Th�f s�ction naad nol be complN�d ff fhs work Involvad by- . ABSORPfION UNIT,BTU OISiRICI NO. W+O ESSED BY
}he parml}ts Ior on�hundrod dollon(SI00)or lots.) � � , '�
I terlily Ihot in the performance of�he work for which this A�R HANDIING UNIT,CFM
permit is issued,I shall not employ ony person in any monner __
- so os fo become subject to the Workers'�Compensotion laws. 60RER,BTU APPROVALS DATE ulsve OR'S SIGNATURE,�
Da1e opplimnt COMPRESSOR,BTU r ROUGH ���(� G�
NOTICE TO APPIICANT: If, afler making this Certificate of VENTILATION SYSTEM FINAL
Exemplion, you shauld become subject to the Workers' r -
�Compensalion provisions of Ihe Labar Code,you must fo�th• EVAPORATIVE COOLER VALIDATION
wilh comply with such provisionz or ihis permit sholl be
deemed revoked.� � - FURNACE: FAU V -
� LICENSED CONTRACTORS DEQARATION FLOOR BTU �p b 9.2 p
I hereby offirm that I om licensed�nder provisions oi Chap�er 9 SUSaENOED UNiT`
�(commenting wi�h$ecfion 7000)of Division 3 of Ihe 8usiness � HEATFR: . WAt "
ond Professions Code e in full force d effed. • •� �• °8- r
0.
Litense Number Lic. lass�����. . . ► � � � C�.2 Jr t�J
ee
CoNra te----_"� . ° ° � C�.2 J u O
❑ r u
I am exemp�unde.Sec. O A� f�8(� w
Pldn check fee y
� 8.8P.C.for ihiz reoson' ' �
- PERMIT ISSUING FEE S �
Date:
Signature TOTAL FEE �
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - �
I herebyaifirm that I am ezempt irom Ihe Conlractor's license� �
Law for the following reason(Settion 7031.5, Business and NAME
Professions Code�: �� �
❑ I, as owner of the property, or my employees with ADDRESS .
wag=s as their sole compensc!ion,will do the work ard �Itt TEI.NO.
the siructure is not intended or offered for sale(Seclion
704d,Businesz ond Professions Code). .,_ -
OWNER
❑ I,os owner of the proper�y,am ezclusively contracting
with licensed mntraclors 10 construtl 1he project(Sec- �"�A�� �
� iion 7044,Business and Professions Code). - ADDeE55
CONSTRUCTION LENDING AGENCY CiN TE�.NO. � � - �-
I hereby affirm�hat there is a construction lending agency for
the perfo�monce oi ihe work for which this permi�is iss�ed CONTRACTO - ►
�Sec.3097.Civ.C.J. . � . . ... . _.. . . - .
. � ADDRESS .._ - _ _. __ . .... . ' . .
Lender's Nome
an
lender's Address � - - �
SiATE IC.
I certify thaf I have reod rhis appiication and sta�e thal ihe. IICENSE No. -� CtA55 - ��� -• �- � -�-—-- -- - ���� .
obove info�molion is corretl.I ogree to comply with all County .
ordinonces and Slo�e laws relating to 6uilding construclion,
and hereby aWhorize repres ntatives of this Covnty to eNer � �� � - - - - �� � -' � -
upon t ob ve- e �o d roperty for inspect'J�pose SEE REVERSE FOR EXPLANATORY LANGUAGE _ .. _
I � � ` .. . .
SignoN� of Applicon�or Agen� �o�e
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