HomeMy WebLinkAbout1148A (5) � 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 . � � � ' � � � �
� � - � n�. COUNTY O�LOS ANGELES � � � Biiii�ING AND 3IaFETii�j
Certified wpy is hereby furnishe . � A�,
� Certified copy is filed with ihe county buildin�eo- .POR APPIICANT TO FILL IN VILD�
� ��n . /1 (PRINT OR TYPE ONLYJ ADDR
� 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 S —
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�� `
� tion 7044,8usiness and Professions Code). DRESS -+,
j CONSTRUCTION�ENDING AGENCY � � � / .
O.
3 I hereby affirm Ihat rhere is a mnsiruction 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 --�- - �- -- �- �� � -'�'-��
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