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HomeMy WebLinkAbout1163A � WORKERS'COMPENSATIONDECLARATION � J� ;�y,� /��,.->Q�pIIrA�IAN �AR PE��l� � � i hereby affirm ihai I have o ceniiicate of consen�io seli '�/�- :�=- �o•. _ msure,or a certificate of Workers'Co ensation Insurance, ��.,��/W or a ceri�� � f sec.saoo . ) � �6Aaeac -HEAT�iNG - VENTILATING - AIR CONDITIONING � '� - CE-818(REV.10/8;) . � a cy. ompany '��� COUNTY OF LOS ANGELES BUILDING AN�3A�E�Y � � Certified copy is hereby furnishe . ���� Certified copy is filed with the county bullding insp o FOR APPLICANT TO FI1L IN BUILDI. � n arime (PRINT OR TVPE ONLv) �ADD y Dote plicant � LOCALITY f NO. TYPE OF APPLIANCE DR EQUIPMEN? . FEE CERTIFICATE OF EXEMPTION OM WORKERS' NEAREST COMPENSATION MSURANCE CROSS ST. � (This section need not be complefed if fha work involved by ABSORPTioN UNIT,BTu oisreicr No. veocess� ev the permit is for one hundred dollars(5100)o�1ess.) � � AIR HANOLING UNIT,CFM I certify fhaf in the performance of ihe work for which ihis permit is issued,-I shal I nof employ any person in any manner � so as to become su6ject to ihe Workers'Compensation Laws. BOILER,BTU qPpetivals oArE ,NSPeaoR's sicNaiuRe `' Date qppiicani COMPRESSOR,8TU ROUGH � / -- .�.G� � NOTICE TO APP�ICANT: If, afier making this Certifimie of �VEN71LAiION SYSTEM F�NA� � �'/�'-. v Exemption, you should become su6ject to the Workers' � y Compensation provisions of the Labor Code,you must forth- EVAPORAtIVE COOLER VA���/�T�QN ' ""��.�. �+ with compiy wiih such.provisions or Ihis permit shall 6e �;., `g deemed revoked. � . . � PURNACE . FAU I �,� � LICENSED CONTRACTORS�DECLARATION F�OOR - eTl,'� . a ____ I hereby affirm ihot I om licensed under provisions of Chapter 9 SUSVENDED UNiT- �(commencing with Sedian 7000)of Division 3 of ihe Business HEA7ER: �� � � ond Professions Cod fn I',ens �i ' full forc and ffe t: � t � License Number � � ic.CI s � .-, � F '�e,�� 67 � f ��,�, � � � . con,.a � '� ,. . � e a�. � � ❑ i am exempt under Sec. . '`c �� r; Fat Plan check fee ` � �� � � � s.&P.C.fo�thrs reasa�� PERMIT ISSUING FEE� � s d�t:�f :;�i:- `—� Dote: � Signatvre TOTAL FEE OWN[R-6UiLDER DECLARATION P'�nN cH=cK aaaucaN? `��� �'��`� � I hereby affirm!hpi I am exempt From ihe Coniractor's license , _, � � Law for ihe following reason(Section 7031,5, Business ond NAME � � Professions Code): ❑ I, os owner of the prnperty, or my employees with AODHE55 � __�_____._._. � wages as iheir sole compensation,will do the wo�k and the sirudure is not intended or offered for sale(Section CITv iet.NO. �� 7044,Business and Professions Code). . � nW NER � .� ' � ❑ I,as owner of the property,am exdusively coniracting Mq i . _ wilh licensed contractors to mnstrucf the project(Seo- . ADDRESS �� „/ � � tion 7044,Business and Professions Code). � � CONSiRUCTION IENDING AGENCY Q i hereby a(firm ihat there'rs a mnsirud:on lending o�ency for ihe performance of the work for which this permit is issued CONiRn ' �. (Sec.3097,Civ.C.). � . = . ..._ . � ADDRES' � � . �- . .. Lender's Name ggg I � L O. E Lender's Address - - .- �� - � ��-�� � STATE C. � I certify ihat I hove read ihis nppli[ation and state fhaf the LICENSE NO.� CIA;S � above informaiion is mrrecf.I ogree to comply with all County - � - � � ordinances and Siaie Inws relating to building wnsiruction, and here6y a�ihor�e preseniatives ot this County to.en�er � u e v ned property for inspection ur SEE REVERSE POR EXPLANATORY LANGUAGE � S�noture of Appiicont or Agent Date . � � '-" - � , .__,�...,:;;:�.,,' : .. � ; ,. Ya,�° _ , a . � -, ; � _ � . '� . . - r „� `. 8/! '"'� - �x '° ' '"�` � ,�;. .>_ � � � :'f`:'"1 � . � .._ .. . , ' . � � '.. - . . - _ � � r' ,>,,�°`.. .. . .�� , :.� .. . . . , : -� ' .:r'� :-_ . _ - ._.. .,..... - � ._......:: ... .. ..... ...:.: . . ..__ ., . ........ '<,�,f'., . - . . . . - r.., • - . . . " �.. . � . . �.. . . ' u �. . . I � ' �. .. �' . � � -" � � f ' i' ; �. � � i � . " � . 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