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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 --�- - �- -- �- �� � -'�'-�� s� q ' i �'� � . -. . �, �.F' �"f�.:^:. : �•.- . �.. - - � �1�� .. , i . :"� .. ..:t . p' j:� .. ' ' .. ..^�� . . 'pr �� �`� .. � . . � , � .� . . Z .. .t�� ' . . ,. ,. . . � y �,�'` . � ... � rl � � . �� .. . " . � . ' . � , .,. .n�9t .. . . . ... •,_.,.., . . .. . ' ' ... . `- ' . . 1 ` ,` ` �, ' � � . � .. � � 1 , � � � � � ���, `, �� � , �', �;; �� � '• 1,, , , ,. ; W�" ':n ° � � m c�o� � , n � . j . 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