HomeMy WebLinkAbout1155A (5) � WORKERS'COMPENSATION DECLARATION �_ ),,,, '/,,., e c�� ��e T�n�� CAD DCDAAIT � �� �
� i�hereby affirm that i have a certiiicote oi Consent to seif �:���j�' 7�_ � ii:ei"a::7.�ic i iiaa : r�a�:na::
insure,or a certifimte of Workers'Co nsation Ins rance, Cf/�f"�
� o�a�e,r� f �se�.aeoo � 76A364C HEATING - VENTILATING - AIR CONDITIDNING �
��} g/ , ce-e�a�eev.ioisi� r 9
� Policy � .. / � mPany Y'� L�/��� '���� f . . ^" ' �/ --_ �
� Cert�fied copy is he�eby fumishe COUNTY OF LO$ANGELE$ BUILDING AND SAFETY `"R
� Certified copy is filed with the munty buildin in p - FOR APPLICANT TO FILL IN BUILDI
tion d (PRINT OR TYPE ONLY) ADDR Y� � .
� Date..�������Plican} � LOCALITY �� � � �" . � ,
NO. TYPE Of APPLIANCE OR-EqU1PMENT FEE NEAREST��
� CERTIFICATE OF EXEMPTION OM WORKERS' cRoss si,
� COMPENSATION INSURANCE
(This sec4ion need not 6e compleTed if ihe work 1nvolved by ABSORPTION UNIT,8TU DiSTxiCr No. vROCe55Ec sv
the permif is For one hundred dollars(5100)or less.) qiR HallotWG UNIT,CFM �
I ceriify that in ihe performance ot the wark for which this
permit is issued,I sholl not employ pny person in qny manner
so as to become subjed fo the Workers'Compensafion Laws. 801LfR,BTU aPPeovr.�s onre iNsaecroR�s siGNnTuae
Date Applicant COMPRESSOR,BTU_ ROl1GH y -
NOTICF TO APPLICANT; If, aNer making }his Certificate of VENTILATION SYSTEM FlNAL
Exemption, yoo shauid become svbject to the Workers' �
Compensation provisions of ihe Labor Code,you must forih- EVAPORATWE COOLER VALIDATION
wiih comply with such provisions or this permii shall be
deemed�eooked. ruaNace� Fau � y�,
� LICENSED CONTRACTORS�ECLARATION FLooR BiU
a
3 1 hereby affirm fhqt I am licensed under provisions of Chapter 9 SUSPENDED UNIT
� -(commenang with Section 7000)of Division 3 of the Business HEATER: W�� �
# ond Professions Code, - my license is i ulPtorce e d e t. �
License Number � f P " ic Class � �
� � ► �
� Contra ' � A a �
g � 1 am exempt under Sec ; �
, _ � �
� Plcn check fee � �
� B.&P,C.for this reason� �
PERMIT ISSUING FEE S ��� 6 = � �*�.
Date:
� TOTAL PEE -
Sgno�ure ;:'�.;
OVJNER-BUILDER DEC�ARATION PtaN criecK naPucaNi � _.
I hereby affirm ihat I am exempi from the Contracior's License � . �' f F ��� ;� '-r-t
Law for ihe following reason(Section 7031.5, Business and NAME
Protessions Code): -
AUUItE55
I, as owner of fhe proper�y, o'r my employees with (t�i ���1 —:Y�
wages as iheir sole mmpensation, ill do}he work and � -�
� ihe siructure is noi intended or offe�4or sale(Sedion CITY TEL.NO.
7044,Business and Professions Code). .� -
�, OWNE. .� I F b� .
� ❑ I,as owner of the property,am exdusively contracting -�' �
with licensed mnirnctors�to tonstrud the projed(Sec- MAIL
� � tion J044,8us�iness and Professions Code). A E55 � \
CONSTRUCTION LENDING RGENCY �� _/
� I hereby affirm ihat ihere is a consiruciion lending agency for - " _ � . �
the performance of the work for which this permit is iss�ed CONTRA oR
� (Sec.3097,Civ.C.). - � -
ADDRFSS .
� Lender's Name �
o.
Lender's Address - �
i
STATE � LIC. -.�
I certify ihat I have read ihis app�kation and state-fhai ihe LICENSE NO. 1 � CLASS .- . -. .. �_.... . ...
above information is correct.I agree to comply with all County �
ordinances and State laws reluting!o building construdion,
and hereby authorize representatives of ihis County to enter - � �- �� � � � � � �-
upoi�tjie bove ey�io properry for i�s ectlo u os SEE REVERSE POR EXPIANATORV LANGUAGE
,�� ���i���� � .
Signni re of Arpllcnnt or Agent ���P � � �
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