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Home My WebLink About1164A (5) � WORKERS'COMPENSATION DKIARATION J��.� ) .�� ps ��eT�n�� CC7o p RAA1T � g I here6y affirm that I have o certifimte of Sonseni fo self ;�(%`/�,f��. :'v:s aVi�. : a.cSS S�eaaxaa S € � insure,or o ceriifimre af Workers'C pensation Insyrance, l� df � or a certi i y❑ c.3 ab. / 76P.3b4C � HEATING - VENTILATING - AIR.CONDITIONING � $ � J//� CE-810(R`eV.i0�&ij 1 o�Vcy N��f�(��a.ny � � // . . . � Ce.ti4ied mpy is hereby turnishe . � � �j t , COUNTY OP LOS ANGELES'� � BUILDING AND SAF� � �Ceriified copy is filed with the munty bullding'ns eo- FOR APPLICANT TO PILL(N BUILoI � n d art e ADDR g (PRINT OR TYPE ONLY) 4 �at pplic - - � -� -- �OCALITv NO. iYPE OF APPLIANCE OR EQtJIPMENT FEE CERTIfICATE Of EXEMPTION FROM WORKERS' NEnReSi COMPENSATION INSURANCE . CeOSS ST. ABSORPTION UNIT,BTU � oISTRiCT NO. PROCESSE�6v (Thie aection need not 6e completed iF the work Involved by „ the permiT is ior one hurtdred dollars(�100)or less.) q�R HANDLING UNIT,CFM I certify ihat in fhe performance of the work for which this � permit is lss�ed,I shall not employ any person in any manner gplLEk,siu - so as to become subjeci to the Workers'Compensation Laws. nPPaovais onre ws�cToe�s sicrvaruee d Dpfe Applicanf COMPRESSOR,BTU ROl1GH � � NOTICE TO APPLICANT: If, afler making this Certificate of VENTILATION 5YS7EM FINAL _ � .� Exemption, you should 6ecome subjed to the Workers' ~ J Compensation provisions�of ihe Labor Code,yo�must forth- EVAPORATIVE COOLER VALIDATION � � v�ith comply with such provisions or }his permit shnll be .�.� deemed revoked: - � � � FURNaCP FAU R iiv � LICENSED CONTRACTORS DECLAR.4TION FLOOa ____�_T I hereby affirm that f am licensed under provisions of Chapter 4 SUSPeNoeo UNii_ � � '{commencing wiih Seciion 7000).of�ivision 3 of ihe Business HEATER: .�� A�� and Professions Co und i (ice e' 'n full force d effe . � � License Number Lic. ass�� / � � Conir tor ' F 1� r; � � ❑ I am exempt vnder Sec. . �„ 9:� .�� Plcn check fee `� � �y 8.&P.C.for this reason- i z, �;_...L.j`.�, � '�} Date: PERMIT ISSUING FEE S TOTAL PEE E ' �' �''% � Signoture_ - � �� - OWNER-BUfLUER OECLARATION - PLAN CHECK APPL�CAM �;, V r � �;(. � I hereby affirm ihaf I om exempt from the Contractor's License --- ► . � p Law for the following reason lSeciion 703L5, Business and nlaME - _ . � Professions Code): ❑ I, as owner o4 the property, or my employees wifh AD�RESS .� wayes as iheir sole compensation,will do the work and . CiiY TEt.NO. - � - - t�.� � ihe shudure is not intended or offered for sale(Sectian � 7044,Business and Professions Cade). � - � �-#�' �- R OWNER � ❑ I,as owner of ihe property,om exclusively mnKactinq . MAIL � � with licensed contradors to construct the proiect(Seo- � AD ess � tion 7044,8usiness and Professions Code). n CONSTRUCTION LENDING AGENCY p . - � I hereby affirm thal there is a cOnsiruction iending agency for ' _ g_ . . . ihe pertormance of the work for which this permit is iss�ed � CONTRa Ok ' ��y � (Sec.3097,Civ.C.J. — i!%�� . . . . . ..-..� ADDRE Lender's Name_— � IT . 0. � . . � . . Lender's Address �� 5 ATE C. I ce��ify ihot I have read ihis application and state that!he LICENSE NO. CLA55 �_--__._ . j above information is correci,I aqree to mmply with all County� � � . # ordinnnces and State laws relating to build+ng consirvction, � and hereby auihori�e representaiives of ihis County to enter opon t abo�e- n p perty for i�spection urposes. 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