HomeMy WebLinkAbout1147A (5) � 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.�"��J1����,�`�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 oisreicr r�o. aaoce�eo ev
(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 ISSUING 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 thc property, or my employees with ��. �,���f;
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 hereBy affirm thot there is a construnion lending agenty 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
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