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 . � � '-"
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