HomeMy WebLinkAbout0854A (4) . ,
WORKERS'COMPENSATION DECLARATION �
I hereby affirm ihat I have a certificate oF consent fo 5e�f APPLICATION FOR PERMIT - �
insure,or a cerrificaie of Workers'Compensation Insurance, 76A364c . HEATING - VENTILATING - AIR CONDITIONING
or a cerJfied mpy thereof(Sec.3800,Lab.C.) ' CE-818(REV.IO/81) - —'� �— -
P❑olicy No. Company COUNTY OF LOS ANGELE$ . BUILDING AND SAFETY
Cerfified topY�'�hereby furnished.
� Cerrified copy cs f�led with ihe coonty build�ng inspec• FOR APPLICANT TO FIIL IN euitotN� �� `,� ����,��� ��
lion department. ADDRE55 (V
. . � (PRINT OR TYPE ONLV)
Dafe Applitam ' LOCAL�TY � ON� B�2
CERTIFICATE OF EXEMPTION FROM WORKER$" NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE NEAREST
COMPENSATION INSURANCE CROSSST.SILtJIFA� GC.C�
ABSORPTION UNIT,BTU
(Thf�saction n��d no1 be completad i(the wark fnvolvod by DISiRiCT NO. vRp�E55ED BV
. Ihe permil��for one hundred dollars(SiDO)ar lecs.) qIR HAN�IING UNIT,CFM �
I ce�lify thot in fhe performonce of ihe wark for which ihis �
permit is issued,I shall nol employ any person in any manner
BOILER,BTIJ
so os to become subjett to the rkers' CIISa1i0�LOw4. APPROVALS DAtE �NSPFCfOR'S SIGNATVRE
�O1e 8� PP�i�a� � COMPRESSOR,BTU ROVGH OZ(7
NOTIC T APPIICANT: If, offer moking this Certifico�e of VENTILATION,SYSTEM FINAL ���
Exemption, yo� should become subject to fhe Workers' _ �
Compensation provis�ons of the Lobor Code,yoV mu5f forih- EVAPORATNE COOLER VALIDATION
with comply wifh such provisions or Ihis permit sholl be �
deemedrevoked. � FURNACE: FAU_GRAVITY
. LICENSED CONTRACTORS DECLARATION FLOOR BTU
I he�eby affirm fhat I am licensed under provisians of Chopfer 9 HEATER: SUSPENDED UNIT_ �
'(mmmencing with Section 7000)of Division 3 of the Business � W/LL �
ond Professions Code,and my Iltense is in full force and effecf. � � � �"
O.
license Number Lic.Closs ' � -- - � � , t�j
�
Contrador �Date � �
❑ I am e.emp�under Sec. `�d��l A W
Plan check fee - - . . . �. . . . .$ N
B.BP.C.for�his reason Da'e. pERMIT ISSUING FEE S U � � � Z
I 3Q50
Sgnature TOTAL FEE .SO � • • •3 Q 5 0 c=a
OWNER-BUILDER DECLARATION PLAN CHECK APPLI�ANT
I here6y aifirm ihat I am ezempt from�he Contractor's License " ' ��� $—8 7
Law i the following reason(Section 7031.5,Bosiness ond NAME��r� G• �E��fy��,,� � '
Prof sions Code): �
I, os owner of the property, or my employees wilh AO�RESS �Q �� �
we7es es the�r<�I=mmpert�a!ion,will do Ihe wo�k and. �ITY /�� 7EL NO.
the strucrure is not intended or offered fo�sole(Settion �/J#1'IQAlD vn'(L �� ��433
7044,Bvsiness and Professions Code). '
� OV✓NER ' G.� � �h-i...i.d;— .
. ❑ I,as owner of�he property,am exdusively comracting r-••��►�*v•
with licensed tontrac�ors to�construct the project(Seo- �''�A�l ,l ��p �r.
tion 7044,Business ond Professions Code). ADDRE55 8ZQ N, /�� _..
CONSTRUCTION LENDING AGENCY CIN ND p/F2 TEt.N0.7/�86O (W� � �
I hereby offirm thai there is a conshuction lending agency for �
the performance of�he work for which this permit is issued �pNTRA(TOR V� Q(,J�f� ,.
(Sec.3097,Civ.C.J. � . .. _
� n�oeess .
lender's Name
� - CITY TEL.NO. - . ..
lender's Address � � -
STATE LIC.
I certify thm I have read�his appllcoiibn and stole�hol the IICENSE NO. � ClA$5 - -- - . -. .. -.
a6ove informotion is correct.I agree lo comply wilh all County
ordinonces and Sio�e laws relating�to building construction,
and hereby authorize representatives of this Coun�y fo enler - - - �� -
�on the a ove-men�ic d pro er�y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
G_`��� g r� g�
Signarura of Applicanl or Agent Dob .. .._ � . . .. . - , _-
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