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HomeMy WebLinkAbout1599A .� ' WORKERS COMPENSATION DECLARATION � APPLICATION ��OR PERMIT � I hereby affirm thar I have a certificate of consent to self � �fnsure,ar a cert�fimte of Workers'Com{sensation Insurance, �6A364C WEATING - VENTILATING - AIR CONDITIONING � or a cerf f ed tapy-fhereof(Sec.3500,Lab.C.} CE-818(REV.10/871� � � � P❑oliry rlo. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. � Certifiep copy is filed with the coun+y building inspeo- FOR APPLICANT TO FILL IN eUuowG �� - ����� fion de arfineni. AD�RE55 . , - . (PRINT OR TYPE ONLV) � Dafe � - APPlimnt .. . LOGAIJTY �NO. NPE OF APPLIANCE OR EQUIPMENT . - fEE� CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST _ {'3, �� COMPENSATION INSURANCE�- . . . CRO55 Si. 75��,4-- ABSORPTION UNIT,RTU_. DISTRICi No vROCE55ED Bv (This seelFon need net be complefed if tha woak involved by . - - ihe permif is ior one hondred dollars(§I00)or less.) � � � I ceriify}hat in ihe performance of the Work#or which-ihis AIR HAN�LING UNIT,CFM' �� ���A� permit is issued,I shall not employ dny person in any manner /�� ��� . so qs.�o become subjecf fo the Workers'Compensation Laws. BOILER,B7U �`_'� qapkovais o.arE iNSNc[roH�ssicNaivaF � � Date��Applicant�..�___ -^" . � COMPR[SSOR,BTU � ROUGH - ��,4C,� �;�_ NOTICE TO APPLICANT: If,��8fter -aking ihis Cerfificate ot UENrIiATION SYSTEM � FlNAL . L, Exemption, you should become-subject fa ihe Workers' � - Compensatiors provlsions.of ihe Labor Code;you must forih- EVaPORATIVE COO�eR � � ' � VALIDATION with comply wi}h such provisions or this permit shall be � deemed revoked. - � � � � FURNaCE: FaU GRAv�iV �/ �A�` 6� LICENSED�CONTRACTORS DECLARATION FLOOR � � BTU � R (�3G/ . f hereby affirm that I am licensed under provisions of Chapter9 SUSPEN�ED UNIT— �� � - HEATER-: WA�� '(commencing�wifh Section 7000)of-Division 3 of the�Business � . and ProfessionsCode,and my license is in full force and effect: � � - �� �/ �^�p� �=f � , � Licenge Number �7��d J Lic Closs� �- � � �� � Con�rqctor ,"�!- � Da�e�` � � � ❑� . . . . . . . � I am exempf under Sec xpy Plan check fee �. B.BP.C.for this reason- � "A PERMIT ISSUING FEE$ (`j �t � Date: signature TOTAL FEE � � � OWNER-BUILDER DECLARATION PIAN CHECKAPPLICANT- � . � ' i hereby affirm thai I am exempt kom the Contrador's License . -. - ► � Law for}he follow.ing reason(Secfion 7031.5, Business and NAME � ���,.�y„ �..�o . Professions Code): - '� - �� ❑ I, as owner of the property, or my employess with � ADDRE55�� � �����,. � . wages as their sole mmpensation,will do the work and F��� , the siructure is not-intended or offered for sale(Section CITY TEL NO. . ,;._'."� ,rj y,t%A � - 7044,Bosiness and Professlons Code). . - -� - � OWNER� � 'f���6 c�o s� � ❑ I,as owner bf ihe property,am endusively conirading MAIL wifh licensed coniracfors to consirud fhe prajecf($er qDDRESS ( - - � �O''���� � --tian 7044,Business and Professions Code). , . � CONSTRUCTIONIENDWG AGENCY CITY TEL NO. - � c ,e o��^ �� s I hereby affirm ihat there is a constrociion lending agency for . ������� the performance of the work for which fhis permit is issued �CONTRACTOR �-- y� �- , n;�,;��5�-�'�5 (Sec 3097,Civ.C.). � . , . . . . . . hDDRE55� �' �� . . � . - . Lender's Name . � CITY �„��� .. TEL NO.���s� , . . Lender's Address � - I certif �that I have read this o limtion and stote that the S7ATe � �4�F,",p� �� LIC. ���y y pp LICFNSE NO. i�J;�d" CIASS ,.L,s _. ., above information is mrrect I agree ro comply with all CounTy � � � ordinances and State laws relnting to building mnstruction, , - . , and hereby quihorize representatives of this Couniy to eNer , � � � � � upon ihe ab -mentioned property for Inspecrion purposes. � . �SEE REVERSE FOR EXPLANATORV LANGUAGE ' � —�—�r—.-�9- � . . � . . . . SignoNre of�Appllwnt or AQent �Dote � � � - �- � - ' - � � � i� � � � � 0 w . �Y _ 1 � " "'_° r � ° y '_ � � _a V =� � c�'.d o � "� ° v ° � j � � us C " � S- �.�1 �ry yp G r,T T.Q v::�� . t ` 1 . . ���- � tl ° o'-a `� c a w ��° '�? � > E' ' o o �- t j k �. � } � �i�A �' � . 3a.a�, D a '`- ` z�.cuaaa� � ti ` -a i" � � n�"Y� � > � � � � � � .V� n �! dx o--��-� c �,u �a`. y s-� ° °'o� a'�' �` y �' uV c,� �� � � . . �� ?� � � p u� � p v' � L �� �� N � '�3 c0 G C O .� v . . 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