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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 ' ,"-\ - � i^.. � .. ,, . . . . , .._. _, � , . . ,r . � , .. , .��'t . , . � .. . , � - . r . .�,. � r Ry � ,3 . . 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