HomeMy WebLinkAbout1156A (5) � WORKERS'rnMpEN$ATION DECLARATION �
r � ���DD`Ii,�Ti�l� �nR �F���T
! I hereby affivm that I have a certifimte of tonsent lo self ����
� insvre,or certifica�e of Workers'Co ensa}ion In rance, . J �
� or a cer+'i�p � f(se�.aso, ��� %"� �en�ac ��NEATING - VENTILATING - AIR CONDITI9NING �
�� .� CE-818(REV.10/BI)
� Policy.. . Co pany v '"�„
� � Cert�fied copy is he�eby fur�ishe . � / �J f COUNTY OF LOS ANGELES BUIL�il�ies ANu�RFETY�' �
�
Certified copy is filed with the county buildin ins ec- FOR APPLItANT TO FILL IN BUILD� -
d �n r (PRINT OR TYPE ONIY) ADD �
� D 5~ � �pplicant � �OCAtliy / �
� - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION ROM WORKERS' nlEa.REST
� COMPENSATION INSURANCE � CR05S 57.
(This section need not be completed if the work involved 6y ABSORPTION uNiT,BTU oisreicT No, vaor_essen a
the permit is Sor one.hundred dollars{5100)or less.) •
I certify that in the performance of ihe work for which th�s AIR HANo�WG UNiT,CPM � F
permit is issued,I shall not employ any person in a�y manner
so as to become sobject to ihe Workers'Compensation Laws. BOiLER,B7U nrveovnis onrr w eaoe�s swNnruae
,..r
Date ApplicaM COMPRESSOR,BTU� � ROUGH
� NOTICE TO APPLICANT: If, nfter making this Cer�ifimte of vENiIIaTION SvSTEM F�NA� /
§ Ezemption, you should become subject to ihe Workers' - -�
4 � �Compensotion provisions-of the Lobor Code;you must forih- Ev�PORATIVE CWIER �//��ID/�T��N '�
`S, �witk comply with-such-provisions or this`permii shall be �
� deemed revoked. FURNACB �AU_ � v
� LICENSED CONTRACTORS DECLARATION FlOOa T 'I .
I hereby affirm that I am licensed under provisions ot Chapter 9 SUSaEtv�ED UNiT�
HEATfR; 'A��
q -(rommencing with Seclion 7W0)of Division 3 of ihe Business N �
and Professwns Cod , d m f en i � fufl force a e t.
�� License Num6er ic.Cioss � . �
Contr � . .� ..�.._ - _. . - v'_:�. �
� � f om enempi under Sec - � . e �$ g� 4
Plcn check fee +� � �
B.&P.C.for this reason� . w�,
PERMIT ISSUING FEE S i = `:i C C
Date:
� Signatu�e TOTAL PEE £ � v<,
:� - OWNER�BUILDER DECLARATION P�AN CHECK APPLICANT — . ,.
I hereby affirrn�hat I om exampl trom ihe Contracior's license �
s��. Law for the following reason(Section 703L5, Business and NAMt � -
� �_G �
Protesslons Code): U� '��r%�'
❑ I, as owner af �he property, or my employees with ADDRE55 .
� wages as iheir sole compensation,will do the work ond -„q�
� the strudure is no?intended or offered for sale(Secrion CITY TEL NO. �
7044,Business a�d Pwfessions Code). ,��
� ❑ OWNER� , ;,r
I,as owner ot ihe properiy,am exdusively confracting
with licensed mniractors ro construct the projeU(Ser - �MAit
tion 7044,Bosiness and Professions Code). ADDRfSS
? CONSTRUCTION LENDING AGENCY
� I hereby affirm fhat there is a consiruction lending ogency for
� ihe performance of the work for which this permit is issued - -�ONTRAC R -
(Sec 3097,Civ.C.). � �, . _ .
� ADDRtS� . � � � . .
Lender's�Name �
CI FI'.NO -
Lender's Address '
� AT 11C. . ..� . . -- --- ..
I cartify thai 1 hove read this application ond sto}e�iha�the LICENSE � QASS
� abovc information is correct.I agree ta mmply with all Caunty - -
� ordinances and State laws relating to building construction,
and hereby auihorize r presenratives of�hrs County�o enter
u on �bo - - t'-n ro en for ins ectio or o. s -
� P ; P P Y ,�'j SEE REVERSE FOR EXPLANATORY LANGUAGE
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