HomeMy WebLinkAbout1145A � WORKERS'COMPENSATION DECLARATION ,_f,� ��.-� J f .-"7 D DDI 1!`ATIAAI CAD PCDAAIT !!
� I hereby otfirm ihai I have a certiticate oi consent to selt �[- %%y� T� : L�w��°ii:� i i�_� � �soavaa:
insure,or a certificate of Workers'Co ensation Insurance, 1�� ' ��� Y�HEATING - VENTILATING - AIR CONDITIONING �
� or a certif���'yyy af�ec.3800�6. 76A3E4C
y ��� .�f� �„�r,F. .,�-,� )� CE-&i8(RFv_to/el)
�'�C an
� Pnlic N �� ��� '�" °4 0� COUNTY OP LOS ANGELES�� - BUILDING AND SAFETY '��`
� Certified mpy is hereby furnished. . �� ��d�
�/�� �
j Cerrified copy is filed w�th the county bu�dm i e- FOR APPLICANT TO PIIL IN Bu����N
3 tion ar m ADDRE,
� (PRINT OR TYPE ON�V)
� Da� � � Applimni � � � LOCALITY �
'r�� J NO. TVPE OF APPLIANCE OR EQUIPMENT � . FEE .
;q CERTIFICATE OF EXEMPTION� OM WORKERS NEAREST
� COMPENSATION INSURANCE Ceoss si.
� ABSOftPiION UNIT,BTU _
(This section need not be completed iF Phe work imolved by oisreia No. Peo�esseo ev
fhe permit is for one hundred dollaro(5100)or less.) � �
� I certify that in ihe performance of the work for which ihis AiR HANDLiNG UMT,CFM _
� permit is issued,I shall nof employ nny person in any manner BOILER,BTU �
� so os ro bemme subject to ihe Workers'Compensation Laws. naaeova�s DATE iN�.aecrae's sieNniuee
�'� � COMPRESSOR,BTU � ROUGH �(L�'^'-� ,,,�-7�.
Da�e Applimni --- -- -----—�
+� N01ICE TO APPLICANT: If, after making"his Certificate of VENTILATION SYS7EM FlNAL �--s�"'
a —
'� Exemption, you should hecome subiect ro the Workers'
�s Compensation provisions of ihe Labor Code,you must forth- evnPORaiive cao�eR VALIDATION '
� with romply wi}h soch provisions ar this�permit shall be __„__.___..___._.__ • �
s desmed revoked. FURNACE: FAU � Y v^� �
� LICENSED CONTRAQORS DECLARATION FLOOR BT
� I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: susPetvoeo UNii_ �
� �(commencing with Sedion 7000)of Division 3 of ihc Business �� �
� and Protessions Co nd my licsnse� in full force nd ett ' g,.
� License Number �- '/ p Lic.�lass ' �
g ConirrbGl,{y[�---�� ���4�T� � e- ��� � iJ
[�
I am exempt ondar Sec. �
� � Plan check fee ,_ { t 5, �
6.&P.C.for ihis r�ason� . �� �
� PERMIT ISSUING FEE$ p�.� F � R �n
Dofe: �
TOTAL FEE
s�g„�,�,�a t e E 4�n G
� OWNER-BUiLDER DECLARAi16N PLAN CHECK AQPLI'ANT �
� I hereby affirm that I am exempt from fhe Contratlor's License - , � il � '� .:C;�`
Law ior ihe following reason(Sedion 7031.5, Business and NAME
Professions Code): �""�'-'�`-
❑ I, os owner o4 Ihe properiy, or my employees wilh ADDRE55 ��r'• -��_ ��'
wages as�heir sole compensafion,will do fhe work and CITY - TEL NO. - �
the siructure is not iniended or offered for sale(Section _
7044,Business and Professions Cnde). OwNER f
❑ I,os owner of ihe property,am excl�sively contracting -
with�icensed mniractors fo mns�ruct ihe praject(Seo- MAII
tion 7044,Businass and Pro4essions Code). A RES'
CONSTRUCTION LENDING AGENCY � '
r�i �9 O.
I hereby affirm thut Ihere is a consiruction lending agency for -
� the pertormance of ihe work for which this permii is issued CONiR 7 e � _
(Sac 3097,Civ.C.).
ADDRE � �
� Lender's Nnme . �
T ?
Lender's Address ' .-
STATE � � _ IC.
I certify that I have read ihis application and state ihat Ihe UCENSE NO, `, CLASS -
above information is correct.I agree to comply with alI County - �
ordinances nnd Stafe laws relating to building consiructlon, . _ _ _
and hereby authorize epresentafives of ihis CouNy fo enter - �
up t ab - e on prnperty for i�ecti9 p�rpos SEE REVERSE FOR EXPLANATORY LANGUAGE
a�
T � .
Sig�fure of Applicant orl�geni Oaie '
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