The URL can be used to link to this page

Home My WebLink About1157A � a WORKERS'COMPENSATION DECLARATION _n j 3,., �J.,.�DDI IP�TIAAI �A iR P�RAAIT � � � I hereby offirm ihat I have a certificate of consent to seif / _ � zsys-�a avam a �re� = m=e==��_ � ;,,s„�e,a�a�e�,�f��are of wo�kP�s c�m ntion Insuran e/, �� ,� ��pTING - VENTILATING - AIR CONDITIONING � or a cerf�i c �/ 3900, ) / 76A364C - � // /{{/ 3JJ CE-b78(REV.10/Bl) 9 ��,,��pp.//��y�^')__/� - PG�iCY��r ' f Q .pn.� '` �f f4��/f!� � � � I ��" J CerriFied mpy is hereby f��rn�she . � COUNTY OF LOS ANGELES BUILDING AND SAtEi`i-/e � �Certified mpy is filed with ihe county buflding i�pe � POR APPLICANT TO F►lL IN BUILDI � ' n de�pqr�n �, ADD - B� r (PRINT OR TYPE ONLY) � LOCALIIY ' � D❑ ,r . e -plican�, - � � NO. TYPE OF APPLIANCE OR EqUIPMENT FFE � � CERTIFICATE OF EXEMPTION ROM WORKERS' NEARESi COMPENSATION INSURANCE cRoss 5T. y (This sedion need nof be completed if the work involved by ABSORP7ION uN�T,BTU____. nisTeicr No. vencesse ar � ihe permiT is for one h�ndred dollars(S10D)or less.) � �i i� � I certify ihat in the per4ormance of ihe work for which ihis AIR HAND�ING UNIT,CFM ,/b ° permit is issued,I shall not employ any person in any manner gp��ER,BTtI � so as to become subject to the Worker.s'�Compensation LQWS. _ APPRVJAlS oarF saeaoa�ss�Narurze S r� � COMFRESSOR,BTIJ _ ROUGH �ate -Applimnt - /a�.. NOTKE TO APPLICANT: If, ofter making ihis Certificare of v=_NraaiiOnl SvSiEM ��NA� , �.. � Ezemption, yoo should become su6jed to �the Workers' VALIDATION �q � Compensotion provisions of the Labor Code,you mus�forth- EVAPORATNE COo�ek '� with comply with such provisions or ihis permit sholl be � deemed revoked. " fURNACE: FAU � % LICENSED CONTRACTORS DECLARATION F�OOR TU � i-hereby affirm ihnt I am licensed under provisions of Chap�er 9 HEnTER� SUSPeN�Eo uNiT_ �' �(commencing with Seclion 7000)of Division 3 of ihe Business � w Y and Professions Cp nd m lice frt fu�l force d e c �` � License Number � lic.� lass-_�e��. .-. . . , GJ . T s� � .._. � �� Conh i e ••_7,� . J O � ❑ naa I am exemp�under 5ec. LL � Plcn check fee � B.&P.C_for tfiis reason' PERMIT ISSUING FEE S Date: TOTAL FEE i ` '' ; �� Signature � OWNFR-BUILDER DECLARAT�ON PLAN CHECK APFLICANT �:. �'a e m e" I hereby affirm that I am eaempt from the Contractor's License ► Law for the following reason(Section 7031.5, Business and NAME f � c. (j,�iA;(j � ProfFlssions Code): ��"- . v_ ADORE55 �" ❑ I, as ovrner of the property, or my employees with ' �� -+� � � wages as their sole compensation,will do Ihe work and Q7Y . . _ TEL.NO. � � ihe siructure is nof intended or offered for sale(Settion � 7044,Business and Professions Code). � � ��r�*�. ��Y� $ OWNER J � ❑ I,as owner of the property,am exd�sively contracting Mnft - with licensed contradors to consiruct the projed(Ser � A RE55 .� � tion 7044,Business and Professions Code}. _ � - - � CONSTRUCTION LEN�ING AGENCY � I hereby affirm ihat there is a construction lending agency for � ��'J the performante of the work 4or whith ihis permi}is issued CONTR C OR %d/ (Sec.3097,Civ.C.). . r- �, • .. � . �. . ..- ... � ADDRES _ . � � -" "� Lender's Name � IT n lender's Address � 5 ATE � ✓ : i I certify that I have read Ihis application and sfaie!hat fhe LICENSE NO. � C!ASS � above Information is corred.I agree to comply with all County - _ � ordinances and S�ate laws relating to 6uilding mnsiruction, and hereby authorize repr seniatives of ihis Counfy ro enter � upo he abo n n property for inspecti pur os $EE REVERSE POR EXPLANATORY LANGUAGE � � � Si9no re of Applicnnt or Ageiii � Dote . 3 / I �l� F \ ' . " . �. ��a" . , . . , 4 ;�•.�::!y�.� . � � � � � � . ' '' . � ... . ' � � 1 � � � � • � � ' I f' I � , - .. .�..6 .._.._ . I ' - x.'� .. f � . i . ' . . . . ... . . y.. x. , .. . . : .�.,.. .. . , ..... : « ' � . . , � , ; .. , '. a' • '..e°"-'cw"�; Y ": J . . .. , i ; j j ., I � - . �'� ' - C80 . � � � � � , . I � I � &9 i I i � i i � , i � ' ; � i � � � : � ' -` � �: _ - � � � Q � �OOn � '� ��4 (Cip��r�j:� �3WO��'�n �W�..a.,� W� �� .. � 3 T- v O � C � ' � � �t�') c� , �roa�no� ❑ � � < mssnocLl�', o �, �na_` Q ��Q � � � � . m �o- a� m F ,— o�3 0 3 Q� a � �Q � Q 2 a ° Q ��' o �n o� o m . . � � , . O� -6 � � u O tp W 3'o �s R j m .',^ �p W v Q o n O ��o u;�Q =� � � 4 'G � ' � vCi� -0 3 t�D -« p�-•'° " a �; ° . S.�c �tt ° r .� .� ,tJ, S2.�-„ '� Q . -� Rj , tn Ti j y � �',�. � F � m `�, a �, "�' �fl . � � o � -ti .�° a�-� � ,,,,,�-w 3 � 0 3 � . � � ^ S$ o� m �: < �.° u.�� °-�,� ` � ��ro ° � � � �'c' Y �s� '.a ' i Q c��n y ° m N = n.° �' ° F ° �° a Q � o Q � � � �' r � �� o � — � , O (p m O w ' Q p O f0 .�. CJ 3 2 7 's � .�,o-� w j G p_� � � y D Q . � � � � o � Y ;� a s o `s" �"ti �m � m �'O c `y o 3 � . . � � � � q �a° ° °=a" m�`� 3 �� a a o ca-a � ° � a'�o w il � �"'b c o� �p� � . ' o O'q �p O T.i �� +.C �� u+P,. O� b o `"5 � � O,j o�� O.•� 0.� � .. is3 � ^? � '^ � m � m"' s�-o � o °.!� 3 m D� �?+ � -, o • 3 � �-a ° ° o� o � � o ' o a m'� o � �'< �. � � 0 3 0 � � fl �° � - - n CL p " II N �� 4d TJ p 7 �Q�� i: K � � e9 4 o vi , � Q O ...:� . � o o � 3 °S o m 'o a o °y — s c ° �"-1 m _. � 3 ' � � � � ='"f m '^ y ° � m F cs ° �- °p��? ° 3 °� � c�° � in � o � c X Q 5, o � � ° +o" 0 3 � 3 0 o a o � =r =� . . i �-,) � y �. n <p� _• ,�� 0� O s w n � Q � � G 7 < n � � . � � 0.�, N �'v' `'�� `J-J Q Os,CJ m � � � O Q j �7 �.Q9 lD � � O � ,� - � .t G ��C b $ � a. � � �4� 7 . . .. � . . - . C O O �_6 � - O 'Z 4 N o O � C � Vi fi1 ��Q . �-Q�j � V � . .. - Q N� � O� S� _i N "p 3 3 O n ZY'Q � � � � ti �� -, c� � . o � ;fl � c� � o aa , o � . o �s.a' o o � �e ? � ' a ru q � a� � a o„�' � v '^ 's cp?' m �- �, cn N --.,--,.��,.. , .._._.�...�._._.�, ..__.�_, ��. ._._.