Loading...
HomeMy WebLinkAbout1148A � WORKERS'COMPENSATION DECLARATION Qpp��CQTIAI� F[)R PEt�MIT 1� - i hereby affirm that i have a ceriificote ai consent to seii �� ���� � ��,s��e,o.��e�,�f��a�e af wo,ke�s co ensation Insurpnce, �6A364C `,����,1LATING - VENTILATING - AIR CONDITIONING � or a cerfi�e��l e.36 , b .� P y ,` CE-818(RFV.10/E'.J � Policv Np � � o oany . � � � ' � � � � � � Cartified copy is hereby tumishe . � ��' COUNTY O�LOS ANGELES � � � BUIiI�ING AND�3IaFETY�j . � Certified copy is filed with ihe county buildin�eo- .POR APPIICANT TO FILL IN VILD� � ��n . �V (PRINT OR TYPE ONLYJ ADDR y � Date � � PPlica ,�». ,,-.` . —_—. .. LOCAiIiv NO. TYPE OF APPLIANCE OR EQUIPMENT FEE � CERTIFICATE OF EXEMPTIO FROM WORKERS' NEAREST COMPENSATION INSURANCE CRO55 ST. � (This secfion need nof he complefed-if the work Involved by A�SORPTION UNii,eiU oisTRicr No. aaoces�v the permii ia for one hundred dollars(�700)or less.) fJ • � AIR HANDLING UNIT,CFM I certify that in the performance of�the work for which this � /-'' permit is issued,I shall not employ any person in any manner so as to become subjecr to the Workers'�Compensation Laws. BOaeR,siU nPezovais onTe Nsaeaou�s sicNnruae � Dote Applicant COMPRESSOR,BTU ROUGH �,��� , „� NOTICE TO APPLICANL If, ofter moking ihis Cerfificate of v[NiIv�,7loN SVSTEM FlNnL i.,�,�� r�' Exemption, you should become subjed to the Workers � Compensation provisions of the Labor Code,yo�m�si for�h- ev.qpORniive coo�ea VALIDATION � � with compiy wiih such prorisions or this permit shall be � deemed revoked. - � FURNACE: PAU A � CR �6 I � LICENSED CONTRACTORS DECLARATION F�OOR B - � --_..__.._._.__� I hereby affirm ihat I am licensed under provisions of Chapfer 9 SUSPENDE� U IT _ fiEATER� W LL � (cornmencing with Sedion 7000)of Division 3 of tha 8�sines5 � E and Professions Cod ., d�rcy*Ili nse.is� full force nd e �, i .,- � � License N�mber ic.�Cla � � . � - . � '� � � � � � Contractar � E �'`��� � ❑ � � i am exempt under Sec :. ... „ ___.._.. __ � {.i-a a c� � a fi � Plan check fee � � B.&P.C.for ihis reason� -..— , � � 3 �� �j,f;�; � PERMIT ISSUING FEE$ — oale: , � TOTAL FEE r = Y<; c{;,";`: � s�go����e OWNER-BUILDER DECLARATION P�aN ci-iecK nFPUCnN? `yz, j I hereby affirm ihat 1 am exempt from ihe Contractor's License � ► �''�,�t�' - „ 3 Law for ihe following reason(Sectior.7031.5, Business and NAME . - � Professions Code): � ❑ I, as owner of ihe property, or my empioyees with ADDRE55 wages as thei�sole rompensotion,will do ihe wo�k and + the structure is noi intended or ofFered for sale(Sedion QTY r TEL.NO. µ� } 7044,Business and Professions Code). OWNER r � ❑ �,as owner of the proper�y,dm exclusively coniracfing � . � � with licensed coniractors to consirud the projecf(Sec- '�A�� ` DRESS � tion 7044,8usiness and Professions Code). . �,' j CONSTRUCTION�ENDING AGENCY �, . 3 I hereby affirm Ihat rhere is a mnsirodion lendiny agency for � �� � � � rhe performance of ihe work for which ihis permit is issued CONiR .O - �. � (Sec 3097,Civ.C.). � ' . . . _ ..._ ._. � . ADDRFSS�� _ . .., Lender's Name i TY f . � � Lendei s Address � � �� � A E IC. � I certify thm I have read this application and sta}c that fhe iJCENSE NO. �'- 9 CIASS - . . . � obove informotian is correct.I ogree to comply wiih all County �� ordinances and State Iaws relating to buiiding consrroction, and hereby ouihorire p senfatives of ihis County to enter - - --�- "� � up th ab n o d ropetty fo�pec'on urp� SEE REVERSE POR EXPLANATORY LANGUAGE � . . . . _.. n � Sig ture of Applicant or Agcnt Date --�- - �- -- �- �� � -'�'-�� -i ,.�^�.,. s.� $ . / » . -. . . , . i:.": . . , .f'.'.S"g"0' .. . . �•.- . �.. - - ' �\'� .. , i . :"� .. ..:t . .� . . .. 1� . . �,r �� �`� .. � . . � , � .� . . �+ .. .r�� ' . . ,. ,. . � � y �,�'`� . ' ... � � � rl � � . �� .. . " . � . ' . � , .,. .n�9t .. . . . ... .,_.;.� . . .. . ' ' ... . `- ' . . 1 , ,` ; �� ' � � „ ; � � � 1 , �A .. =� `, �� � , �', �;; �� 1 ', `\ + 1,,, � , ,. : �;�� :nQ � � m � � . � � . � _ , .. ''. V� v' � (� C 1 t � � ' n "1 O q n ^-� ,�,�,N � �� � � � , , - s a4 � N Q n �n `� *^ '" o, {� 1 ' � o� c� Q ��- fi� � rt�- a.Q � �2. �� - � � 3 p � �-a p �T m- �' ^, rl V, O � O ��.A O Q O"6,i1. ''� ,. O v 6 0.c9 .3 3 PJ � � {P'e . �.L^Q O S'"SS j Y. C� t,�..,a n � e�°,a K {i tb O�a (p '�b N^3J, ''..O � � . . ' � �C ?O-�� �-+ � � �'-s fl (D � �• � A� �� �� �c�C Q �-ti �n � - c� S 4 '� . ' �..-. . (W f1 O �` � f'1 � tY� n-� Q..V� 9 O<. N S9 R � C v' l0 l � ' � ip 4 Cl 5 0'�`-o`° V cL c 3 0 � '" m m� N o • �0 0.9 ��.@ � „ o N � b 620 3 3� �•c, Q�,=' 0 1� o .,,o a � � � �cc-�M �.` � m �� � ° o � �O .. (� , m a-v� ?m � in �� `{ W�o �D 9 ii m N v_'.fl f]-� � = C`i� N � , '`� � �Cl � fl�, o r W � ° v �. ` ra �v a n ?.� � 3 v � � �� "v.i;Q-� 3 s'7 @ � o � � 3� o =o cLsto y � c� � o x `�'n� ro °,- ��%`° t'n o . -O �;�� �� � c� � <a o�.m � °a�� ° � � a,Qpw o �'� 1' � � rs- o c�o o � � w �.y ° � c�. o pfl � -n � 30 � � n .,. N � m a ° ,`Di, ° 4 S g� °�'-°L-y cu �. °v -° s� m m o "` - �, o o � � � o N o °'?.� 's a � `D �, �'+s �, o � 3 m '� m a� .. � °'N. 3 .< � � � � � O Q.P � r .�-a." � '"� A U O ti„G tU K � ' .0 � �. < y, lq '-�� �y'O Ui 7, N (p Q � ^� O Q.O "6 Q,� �,a � O � � �G � �r O �.. .] a..6 cq fl pG p �Q � 4- . . , . . O fs ,4� n �p-O v, O�('J 'O t0-z O S] 8"3 C-�. ��"C a � N 3 O fl 3 Q p n . 0 O K u� in Q � Q r{ � � � Q 4- �' � � u� 7, G .N m C O O CJ ��j 0.j N? o ° a.� m ° ` o �-° m. ° ° ��� � ti � � c� < ,n _�? nN� �ooWroS� �� � � �, oQQ �� ¢�o �oo _ � Z °�p-` x o�3 ro m ° o � � � s� v�m '�`a o,...Q �3 n v, N N � � •L. � �r m cn-o a� Q- n ° � c n 4°�.:r ca m � .,�-r'. ? � N O Z� � m .. Q ry m 5 �N.v rt Q Q'.�.� � � 4 N�C "" s 'I./�� � - � o Ts.n� m .,�� � m v! ro fl 2 4- � �,.--� N �C.<' i� ' tII � �n � ,,�+�,.�-"' - . � 9 O .�,. C C' O-:S� C3 ? � \ Tl _ . O q' ;9 -� Q iy � , .� �_ � n � �� o.% � 0 �I��.,----' a �,,..�,,,,,,, �,,,,,^" �r,,,,..r-^'^ _.....-°"'"..,.,.-^.",.