HomeMy WebLinkAbout1132A (5) � L WORKERS'•COMPFNSATION DECCARATION ppp� ��pTInN Ft�R PFRMIT �
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� 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 �
� NOT.ICE TO APPLICANT: If, after making this Ceriificatc of vENTILA7lON SYSTEM nNA� �(.v'��'`��� i,i��
? Exemption, you should become 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 . .� � °�.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 � - �
ff� Professions Code):
� ❑ L as owner of ihe proper!y, or my employees with 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 ,.
I CON57RUCTION LENDING AGENCY
� I hereby affirm ih�l there is o consfruction lending agenry for Giv Td24v OTi. B2dCh �2�760 iE�.�N�14) 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
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