HomeMy WebLinkAbout1157A (5) �
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 .
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