HomeMy WebLinkAbout1146A � WORKERS'COMPENSAT�ON DECLARAT�ON � ,�r„1 e p�1 �(`A TIAAI r.�D DCDiAA1T �
� I he.ghy pFf;...,. iV.o� I hov^C LF.'ll�:C�4c•_?f,p••59.^.!tG sei;` ��/i.. /V/�"' IlC � S w:o o�V a� i6 i Ln Vii i �
� insure,or a certificate of Workers'C ensa,ion In urance, �6a364C � ATING - VENTILATING - AIR CONDITIONING
� or a ce�cd' r�f 380,�b _ �
AtJ 4^- CE-818 1REV.10i81)
Po�icy " o pan ppj�'�� I �y�.�,
.Ce.rified copy is hereby tu�nis e : �i�a J��� � COUNTY OP LOS ANGELES �f� BUILDING AND SAPETY�
v
� Certified copy is filed with ihe co�niy building insp o- FOR APPLICANT TO FILL IN eu�tD� �
ljon c�pGs�rlle (PRINT OR NPE ONLV) ADD
✓
1 '
y Oat� , , �ppllcant , / . LOCALITY '° ` .
� NO. TYPE OF APPIIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION F OM-WORKERS' -_— — NFaRF57
COMPENSATION INSURANCE CROSS 57. �
(This section need not be completed if fhe work�involved by� AesORP710N UNIT,BN _ oisTeict No. aeocFs��v �
the permif is for one hundred dollors(5100j or less.) � � z����.,
I certify that in the performance of the work for which ihis � A�R HAN�LING UNIT,CPM �
� permif is issued,I shall not employ any person in any manner � --�- �
BOILER,BTU
so as to 6ecome subject to the Workers'Compensation Lawa . nvaeovais onre �Nsaecroa�s si�Naruue
Dqte Appl�cani COMPRESSOR,BTU ROUGH „ ��' �'�!='Z...-
NOTICE TO APPLICANT: If. after making ihis Certifimie of vENTI�ATiON SVSiEM FiNat
Ezempiion, you should become.subieci to ihe�Workers' -��
Compensation provisions of the Lpbor{ode,you must forth- EVAPORATIVE COOLER VALIDATION �
with comply with soch provisions or this permiF sholl be
deemed revo�ed. FURNACE� FAII AV .
LICENSEQ CONTRACTORS DECLARATION� fLOOa
I hereby affirm ihal I am licensed under provisions of Chapter 9 SUSPeNoeo UNI7_
HEATER: W ��
�(mmmencing with Sec�ion 70pp)of Division 3 ofihe 8usiness � �
- and Professions Co and y licens � in full tor and �
�y � �
LicenseNumb r °7 Lic�G s � �
�.-�-�' � � �, � � �
Conir+acierf--' a �
DI am exempt under Sec. ` � -�--�- �— �
Plcn check fee �
e.&P.C.for this�easo� Date: ___ PERMIT fSSUING FEE$ � , �
` "'�I';
TOTAL PEE A c:
Signqtore_ '`µ' a ^ F s „
� OWNER-BUIIDER DECLARATION P�nN CHECK aNNUCAtvr , �
I hereby affirm thof i om exempt from the Coniroctor's License � � j a s[!Q,_r C�
Law for fhe following reoson (Sedion 7031.5, 6usiness and NAME � � .
Professions Code): � » r, re;��'(;`l?,
❑ I, as owner of}hc property, or my employees wifh A��RE55 —
wages os±heir sole compensaiion,will do the work and CITY TEL. Q � I``''�'����"� �
ihe str�cture is not intended or offered for sale,(Section - . �
7044,8usiness and Professio�s Codej. � / -- ��- �
OWNER �
❑ I,as owner of ihe property,om exdusively confracling
wiih licensed coniracrors to construd ike project�Sec- . MA�� � -
tion 7044,6usiness and Professions Code). AD RESS .
CONSTRUCTION LENDING AGENCY �
I hereby offirm thai there is a mnslruttion lendinq agency for
ihe performance of the work for which ihis permit is issued CONTRA �O / .
(Sec.3097,Civ.C.). � - �: .• : . . . ...
� AD�RE55 -� - - � . _. . ..
Lender's Name . - _
I N� . D. � - . .
Lendei s Address ' � -
STATE
I certify that I have read ihis application and state that ihe i.iCENSF NO.� � � n5S - .
above informafion is corred.I agree to mmply wifh all County .
ordinances and State Iqws relating to building mnsirudion, � .
and herc6y outhorize represe tatives of ihis County�o enter . - -�
� upon above- ��n r'perty for inspection oses. SEE REVERSE FOR EXPLANATORY IANGUAGE
�� � �
Signanr ot Applicanl or Agem � ��a+e _ - . -
�
<�
; N :
'F,
frY+ .
�.� . .I" �� � � �� .
SF. � . . . .. ..
ij!
J,. ' '„ ' .. ... . ... :.
� 4°'.
t � „�p � e
� ,.
� _ .
a76 .
�
a�A{
dlg .,. .:.. � ,-.
: \
r 1` �'
� . ' � ' u� ;�� .
'. . . � . : , '� . .
t r �
3 j t �
.; I ` . � � �';.'
�
. . - ,p�/.. � .
�, �
�; � - � � �
. - .::.
. �
. , , .
1 ` ,- .
�, � ,
� � � . . � � .��n T '
. .L` 4��w.� �
. ' . , ,' . ,.N�V`p�� G. ' G a u� �a.. .-� . �
. . �'!l �� � !�o '�.a- N'� tA f r.� iLl
. . . .�� O � L:. `�„ p a =:3:a��n Q Q � Ly
.,� p V' i9 5 ('1� �. f� ry n � � +,G-
} . '; : � _. � � m Q vi,� O ,-a O C�^6 LL
� � b 3 > p Q ,r" -� C1 w o a- n.o - .a ,� � 'o 0 3 s';'+
���'` "� q �'O � X" � 0� --R n-G Q N O�^ �cG .gi `� O � �}. .
N Q �4 � o a-�S c.m �'°'-G o�.° � ;. n Fi "' cn �`4 't1'
� � � - . . '" c S -� 'n". �S' G W 7 ?' (� a o <'t N� �� n �- = Q �in t9 � 't.-�-., .
s wa..3 0'. � �- � = w o �
°a N ^}
_ _ (QV. . Q O•-�g. (0 �' /Q O (y� O "e'�n ��.`7 7 .� (D���'G�RO '0�N N O > SJ
� � ,. Q '� � Qo � .�]+ a 2��' �"p, c� -a `t N�° � p � �� �,o ° -�p c .o �.k �.
q,� p -o m Q� N � co : 0 3 ��' � 0 3 a.�, p o„ „G � � "' s `� c ��° n o.� rn C3
rz m �C' m ^. ,� � o u� i� `z a _�a3�o���O @ � � 3 0. M w r;+^ -o ° ' �� � f�
� p .: m 3� O O �n � o O io �'Q co s?� � f
m o � ��.3 a� � `� m <.£° °_ No "cm -� � Q 3 °-°6 � 3 ° �� o ^' , p
-. "
� c-�-'4 a 's a,a.o co .: � �s o °' � � ��= �-� v; ,:- � o o r �
S. � „ � o co o � �, �fl Q S� � t, .o � � _. m o � .. � 3 �
(n O- N c+ N �} Ci"� t9 T� � �_ N m-.'C'' �in,O ^ O �j"�.(p..Cp 7 ..,� N -'�Zy-L tn 5".
� m � O D �o � (0 GT O .+,n �'G.O -� --��. tC _ �-� co c; p �, cu n . �.
. . " 4� � .^��-.�?'�o n � 'c ��i4��-'� s o v� � �. � c n C`�,3 o n 4.� o p p �.
ro 'U
o n ; ° m`e � �,�co� v �� �`c 3 a � o°"` c7i c � � 3 '` '^ � ` "
, S . .� O �'t u' ^� OU p�4 4'6 �O.a-O p � � � j a � O� N < ".1 O ..
O � N -., n W 4 Q n�
.. , .. . .. . �+ �n�yG'j 0 O�� �f�'P �S� �y�N �S T.�",a �c�c3 O 9' d u�T �U,'n
� °- o v �o 's� a s Z s m cr,c� a „
� g � Q,,. X a � 3 � � �o m o � � W �o � �� q s s- �_,--.
,, � � � ec n � m m-o �' N o�v o x' �a ro .° cu a-� �,
. N O � --1 ' N � S w�' [y N O 7 �,j , �
S G .�.r O �-: � y... O � � r.� !..-
- ` ..Q O O t9 N � . �,3 = �. Q !
� -p C�1 1 N ' tC 7 n "' �„-.
9 �r-�. q S'G
, . � j G Q O �, Q c a'm 4 ��~�.-i�
., � �@ `a' m � a- ,../
-. .. � O� � ,--"'��,-
� � . 'o �.,...--""
. _ I"�..,rr""'
I'�,`
� -'��.
�
_/���
.-%��
�.<:,�,��--