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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 . 3 � . . _ ,�,�x:� ''�` � '.�:: r' . 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