HomeMy WebLinkAbout1146A (5) � 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 I
.Ce.rified copy is hereby tu�nis e : ���� � COUNTY OP LOS ANGELES � BUILDING AND SAPETY�
�Certified copy is filed with ihe co�niy building insp o- FOR APPLICANT TO FILL IN eu�tD� �
� on c�pGs�rlle�}j,.� (PRINT OR NPE ONLV) ADD
Oa�E��, ,� %0`.d.ppllcant � � - LOCALITY �° "
� l � � NO. TYPE OF APPIIANCE OR E�UIPMENT FEE .
CERTIFICATE OF EXEMPTION F OM-WORKERS' -_— — NFaRF57
COMPENSATION INSURANCE CROSS 57. �
(Thia section need not be completed if the work�involved by� AesORP710N UNIT,BN _ n�s*Ri^r uo, aaprrs��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$ � , �
,. �
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 ihe property, or my emp�oyees 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 conslruttion 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 with all CouNy .
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 _ - . -
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