HomeMy WebLinkAbout1599A (9) .� ' 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 '
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