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Home My WebLink About1147A � WORKERSCOMPENSATIONDECLARATION � � n eap11��T�nr� CAD DCDA/'�'r ,B : he•=by acfbrm i:�ai i r.ve - ceriincaie cr corsart ro seii /� .a a eiii i V�Y i i.iCii"i ; insure,or a certiticate of Workers'co nsafion i�s�ra�e, 76A364C� `,�tl�°�ATING - VENTOLATING - AIR CONDITIONING � or u certifi .h � 00, .C � n � � '� / CE-ei (REV.10/Al) Policy No � �. �[ P �Y . � r . ` � Certified copy is hereby furnished.�"��J1j��,�`�j� COUNTY OP l0S ANGELES BUtLDING AND SAFETY=—� �} � "--o• �.r•i � , Certified copy rs filed with the munty building inspe- FOR APPLICANT TO FILL IN BUILDIN tion d � ADDRE / � � (PRINT OR TYPE ONLYj � Uate �p�icant — --- LOCALI?Y � ' .NO. TYPE OF APPLIANCE OR EQUIPMENi FEE CERTIFICATE OF EXEMPTION FR WORKERS — NE.4Re5i COMPENSATION INSURANCE . CRO55 SL � ABSORPTION UNIT,BTl7 DlsiRlci No. PROCE'ED eY (This section nead noT be compleTed if the work involved by � � � fhe permit is for one�hundred dollan(5100)or less.) qiR HANDUNG uNIT,-CFM '� I certify fhat in ihe performance of the work far which this . pennit is issued,I shall not employ any person in any manner - so as to become subject to ihe Workers'Compensation Laws. BOILER,BTU naPeovn�s o.are wsPeaoR•s sicNnruae � Date Applimnf COMPRESSOR,RTU ROUGH ��+� �i� ---'r NOTICE TO APPUCANT: if, afler making this Certificafe of VEN7ILATION SYS7FM FINAL r� , � Exempiion, yoo should become subject to ihe Workers' • Compensation provisions of the Labor Code,you must forth- EvaPORa7ivF COO�eR VALIDATION '� with comply with soch provisions or Ihis'pennit�sha�l be . deemed�e�oked. � ruRNacE:. Fau_� �v - LICFNSED CONTRACTORS DECIARATION fLOOR B7U � . I hereby affirm tha!!am licensed under provisionsbf Chapter 9 SuSveNDE[7 uNii_ � HEATER: '(commencing�wifh Section 7000)of Division 3 of ihe Business A« and?rofessions Code�d m�i i,�n�i foll far- ❑nd , ci. � T �' license Nurnber l —y k.U � �✓°� - ► - � ��` _ ' �-� Contratl � O ❑ I am exempt underPSec.._ —��-- � Plan check fee � B.&P.C.for this reason PERMIT ISSUlNG FEE f '_ i �'• �.'� � --�.._.Date: � TOTAL PEE t' ,: � _ � a t. Signat�re�.._ " " OWNER�BU�LDER DECIARATIQN �LP.N CHecK AaPUC.4N? � E �, � G„ � I hereby affirm ihal I am exempt from the Coniractor's License I,�w for the folbwing reoson{Sedion 7031.5, Business and NAME ► � , .. 4!=r,(;?: Protessions Code): � � �" �" �� ADDRE55 ❑ I, ns owner of the property, or my employees with ��- ��{� wages as their sole compensatior,wil I do the work and " ^� ihe sir�d�re is not intended or offered for sale(Section Cliv TE�.NO. . 7044,Business and Professions Code). � � OWNER ❑ I,as owner of the properry,am ezclusively contratling with licensed contractors to constr�ct the project(Seo- MAIt - tion 7044,Business and Prafessions Code). AD E55 - . � CONSTRUCTION LENDING AGENCY 7� �� ) `�.. � I here6y affirm thot ihere is a consirudion lending ngenty for - ihe perforrnance of ihe work far which+his permii is issued CONTRAQ . (Sec.3097,Civ.C.). I . � . . .. . .— ... ...• .- ADDRESS: .:. .. � . .' . _... Lender's Name ^� +' � Y 6 Q � � --- �. I.ender's Address � � � ~ - S A E J � I [erfify thot I hove read this appliwtion and stale that ihe LICENSE NO. �- . CLASS � . above informotion Is mrrect.I agree to comply with olf County - � � ordinances and Siate lows relating fo 6uilding consfrucfion, , - - - and hereby authorize re�resenfatives of this County to enter � �� . � �" -� upon he 6ov ptiq��r�r inspe��on�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE _ � re � � J Signa af Appllcant or Ageni Uote . ' . . 'fr {'� ' _ ..._ . . � � " � V'_.E . . - .. �� .• ' . . � �"�,:Y" , S . . 't�� I , . I ✓ . Z .J .. -. _ ., . . "� f'�� . . . ' . Btt : i`.." A o .. � . .. . .. .'`'� � . . .,. . � � . . . . . . ... .. �4 � - - . : .. .. ... � � a,. - . . ... . _ ,. ,. RSI . . .. .. _ . � .� ' ' k . ';e...�+`� . . � F� r.<^` � � � I � � � ` � � • . �( j ..,.. .,.. .. i ., � . i 1 ` I � ,: � . , �,:. 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