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Home My WebLink About1132A � L WORKERS'•COMPFNSATION DECCARATION ppp� ��pTInN Ft�R PFRMIT � � � i nc�euy u:::,��i ��u, i � vc �eni,�mie oi conser i �o seir • :• • �•�• �••o•� . +•m • m.�•s••• . g� insure,or a certificate of Workers'compensnrio��nsu�nnce, �6A3r�4c HEATING - VENTILATING - AIR CONDITIONING � or a certified copy thereof(Sec.3800,Lab.C.) - . � CE-elB(REV.10/81) � �� )�� Policy No. i mi s�F Companv State Fun� �`';!j � L ! Certitied m is hereb fumished. n "' ` �OUNTV l7F LOS AN(`aEi.ES u BUIL�ING AND$AFETY �, � PY 1' TR;; 4�'�� JOSrr 1111 PH$ 333 � Cert�ied copy is filed with the ca�n��t}}}'''building inspeo- FOR APPLICANT TO�ILL IN BUILDWG � � lion deparimenf. � ADDRESS � R r1Ve `. 1 � (PRINT OR TVPE ONLY) – � �a�e 7_�3_S7— APpu�a�r ° �ocauTv NO. TVPE OF APPLIANCE OR EqUIPMENT FEE g CERTIFICATE OP EXEMPTION F M WORKERS' .. . -- -- NEAREST Y COMPENSATION INS RANCE CROSS Si. ABSORPTION UNIT,BTU DISTRICi NO. � CROCESSED BV (This section need�not 6e completed if.the work invoWed by G � the permit is for one hundred dollars(S100)or less.) �,� `�„! I certify that in�he performance of ihe work for which ihis AIR HANDLING UNIT,CfM p parmit is issued,I shall not employ any person in any manner � so as to 6ecome subjecFto Ihe Workers'Compensation Laws. BOI�ER,BTU _ qppeova�s oare �rvsaecioR's sicNAr�RE 9 Dafe Applicant COMPRESSOR,8TU � ROUGH � � NOTICE TO APPLICANT: If, after making this Ceriificate of vENTILA7lON SYSTEM nNAi ��;.v'��'� i,r� � Exen��liori, you sfiould becorne su6ject lo the Workers' ---�--- �-�- � Compensation provisions ot the Labor Code,you m�st forth- – Eva�eanve coo�ea VALIDATION wifh wmply with such provisions or ihis permit shall be JeemeJ I'eVolteCJ. hURNA(:E: fAU GRAVITY LICENSEO CONTRACTORS DECLARATION Ft0 e �TU � I hereby affirm that I am licensed under pro�isions of Chapter 9 SUSPENOED UNIT_ �(commencing wifh$eciion 7W0)of Division�3 of the 8usiness HEA7ER� WA�� and Professions Code,and my license is in full force and effeci. �' f� ,�� License Number_ �q�� Lic Class�_ – ��— , . � � Ccntractor Tr�iin-.SOP Date 7-23-87 � � I am exempi under Sec. � ---�— _ �-� �' �'� � Plan check fee �, a ° � . �- : g '` � 8.8P.C.for this reason PERMIT ISSUING FfE$ � � Date: r . .� a =�.Si .r.� Signature TOTAL FE� ��7 � � .!.t �.�;�z r OWNER-BUILDER DECLARATION Ptnn�cHecK nPai icaNi ��v u"�� I hereby affirtn ihal 1 urn exempl Bom the Controtlor's License � law(or the following reason(Section 7031.5, 8usiness and NAME � - � fff� Professions Code): � ❑ I, os owner of ihe proper!y, or my employees wirh ADDRESS � wages as their sole compensa`ion,will do the work and the strudure is not intended or offered for sale(Secfion CITY TEL NO. 70A4,Busine s nnd Professians Code). - � � OWNER � ❑ �,as owner of ihe property,ain exdusively confracting wifh licensed contrqctors io consirud-ihe projed(Sec- MAII tion 7044,Business and Professions Code}. AD�RE55 ,. � CON57RUCTION LENDING AGENCY I heraby affirm�hu�there is o construction Ir.ndiny agenry for Giv N24v OTi. B�2.Ch �2660 iE��NP`I14) 833-3600 � ihe performance of ihe work for which ihis permit is issued CONTRAQOR (Sec.3097,Civ.C.). - � ADDRCSS Lender's Name � CITY IEL.ND. . lendar's Address Z' – � SiATF � LIC. I certify Ihai I have read this application and stoie that the LICENSE NO. CLA55 � above information is correct.I agree to comply with all Coun�y � � � � ordinances and Sfate laws relating to building construction, and hereby authorize representatives of this County to enter - � . . u n the nb ve-mentloned ro ert for ins ection or oses. - �' p p y p P p SEE REVERSE POR EXPLANAiORY LANGUAGE � ,, A,J Sir ature of Applicant or Agen+ Date ' � - � , . ' . � .. �..' ,�«�;t. .:M �h " � � 4 � � . , .. " . � . 3/! '� � � '`t` ,� � \ � \ 1 � 1 � ��.d �` � i} ` 4 '. t� ` � . 3 , i , .. 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