HomeMy WebLinkAbout1143A WORKERS'COMPENSATION DECLARATION ���j /� pC� � �
� �,-.euy�fiirn� tf�u' i navc a cer'ificae or consent ro sei> '("���`r'�(j�e�p�!S.+a-eaT�viU -.Ca�.�� i"GS`+v�iT �
insure,or a cerfificafe of Workers'Co ensation Insu a e, �'( " � �•(0
� a,a�e�uyre� o . 0���00,�a .C. 76�364C HEATING - VENTILATING - AIR CONDITIONING
�+ CE-818(REV.t0/87)
Policy N�' � n
`� Ceni fia d copy is he�e by fomis�ie . , �� COUNTY OF LOS ANGELES BUILDING AND SAFETY� �
Certified copy is filed with�he coonry build g i s'p c- FOR APPLICANT TO FILL IN Rui�o�
tion de rt nt A��RE 5� �
(PRINT OR TYPE ONLY)
� Oa�e "� �plicani . ./�f. � IOCAtITV � ' .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPiION OM WORKERS' NEAREST
COMPENSATION INSURANCE � CR0.5S 57.
� (This seclion need noi be cumpleted if the work invulved 6y �+BSORPTION UNIT,BTU oisre:cr Nn ca�cF. �o ov -
the permif is for one hundred dollan(SI00)or less.) . /�J � j�y�
AIR HANDLING UNIT,CFM_
I rertify ihat in the perfonnance of the work for which this L� '�
permif is issued,I shall not employ�ony person in any mannar
so as to become subject to the Workers'Compensation Laws. Bn��ER,sTU nvveovn�s oATe � wsaecToe's sicNnruee -
Date Applicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATIONSYS7EM FiNA� . �`� -.c`^
� Ezempiion, you should become subject to�the Workers' --�.--- --" -
Cotropensation provisions of ihe Labor Code,you must forth- FVAPORATNE COOLER VALIDATION '�
with comply with such pravisions or this permit shall be
deemed revoked. FURNACE: . fAU IT �
LICENSED CONTRACTORS DECLARATION FtOOR B
I hereby affirrn that I am licensed under provisionsbf Chapter 9 HEATER� SUSP[NDE 11N11_
�(commencing wi}h$ection 7000)of-�ivision.3�of�the Business - � �''�h"��
and Professions Co �ndQ,my i�n e i '-fulPforc�and c �-�
���� _ � �
�icense Number'�� Lic.CI �f .
aP.
Conir �
€�
❑ 'u.
I am exempi�nder Sec.__._ �
Plan check fee
B.&P.C.for this reason- ''- f � �' °'1� �
PERMIT ISSUING FEE$ #t'� F � F. �fi.
Do�e: .,.---
TOTAI.FEE
Signature__ � .1 ro �±4%�r�i :
OWNER-BUILDER DECLARATION PLAN cHECK APP!iCANi
I hereby affirm ihat I om exempi from ihe Coniractor's License � m o k�.� �!��f':!�'?1..
I.aw for thc fol!owing reason(Sec?ion 7031.5, Business and� NAMe -
Professions Coda): - . (�ij,�:1! «-��fj -_ .
❑ I, us owner of ihe properfy, or my employees wilh ADDRE55 . -
wac�es as their sole compensation,will do the work and CITY Te�.NO. � �
Ihe slructure is not intended or otPered for saie(Section . ,
7044,Business and Professions Code). 1 �
❑ OWNER f✓ . _
} I,os owner of fhe properiy,am exclusively mntracting
� with licensed coniradors to consiruct the project(Seo- MA��
� tion 7044,Bus�ness and Professions Code), ADDRESS � s�
� CONSTRUCTION LENDWG AGENCY . ��� _
�� I hereby affirm thot ihere is a C�nstrudion lending agency for � �� � '-` - �. �
ihe perfo�mance of ihe work for which ihis permit is issued CONTRA 0 ,
(Sec.3097,Civ.C.j. .. �� . . . . . . . . .. .
ADDRES ..� � -
Lender's Name
IT '/
Lender's Address -
� ATE .�� . . ...
I tertify ihat I have read ihis applicalion and-slnte that fhe IICENSEN�_ , LA55
obove informa�ion is correci.i agree ro comply wifh all County
erdinances and Stare laws relaling to building construction, � � ,
and hereby authorize represeniatives of this County ro enter _ . �
upon ihe obove- ti ned ro erty for inspeciio�pur oses. SEE REVERSE POR EXPLANATORY LANGUAGE
�� �.� � ����
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