HomeMy WebLinkAbout1149A J WORKERS'COMPENSATIONDECLARATION ��j �/�ll„�ePPI l�'ATI[11U CAD P�DAAIT ��
� I nefeoy u?ilrm ihGi I have G Cerliiicale oi mnseni b self � �/ !���%��a a iaa�ra a avo= : �sa o �seaeaa a
¢¢¢ insure,or o certificote of Workers'Co ensation In urance, Y�� `�"' �
jjj3 a,o�Pmf��r/g-��j���� seoo � . r C6A3848(Rc✓ �E) HEA?ING - VENiILATING - AIR CONDITIONING �
y Policy N� "P�. � mpany � .Y— _ A � � .. �
� � Certified copy is hereby fumi'sh� . � ���vy''�f�✓ COUNTY OP LOS ANGEIES � BUILDING AND SAFETY"
/ . !/!"/ I -
� ��,f Certified copy is filed with the county b�il in is c- FOR APPLICANT TO FILL IN auaoi
oJC f'on�g�py�n�/ (PRINT OR TYPE ONLY) ADD ��
��g/Y�! �
p� � 4✓�Applitar� /` IOCAUiv
4 NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTI FROM WORKERS' . NEAREST
COMPENSATION WSURANCE CRO55 S7.
(This sectlon need not 6e complefed if fhe work involved by ABSORPTION UNIt,8TU oisreicT No. ppp��� akocesseo.gr
� ��
the permit is for ane bundred dollars(S100J or less.) �
I certify that in the pecformance of the�work for which ihis AIR HANDI.ING UNIT,CPM �
permit is issued,I shall not employ ony persom in any manner
so-as to 6emme subjecf to the Workers'Compensation Laws. gOILER,BTU aaasovnt5 DnrE t• FCToa's sic,Naruee
Date Applicanf COMPRESSOR,BTU ROUGH _ r� ���r'
NOTICE TO APPLICANT: If, otter making ihis Certificafe of VENTILATIONSYS7FM FINAL �,� .G,�
Ezemption, you should become su6ject fo ihe Workers'
Compensation provisions of ihe Labor Code,you musi fiorth- EVAPORATIVE COOLER VALIDATION �
� wifh comply wiih such provisions or this permit shall be �
deemed revoked. FURNACE FAU RA
LICENSED CONTRACTORS 6ECLARATION f�00R U
� I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
HEATER� W ��
�(commencing with Section 7000)of Division 3 of Ihe Busi ess �,
ond Professions Cod d my �cense� �n f�ll force d e n c g4
� license Number� � Lic CI ss , �
� ' r —
f: �''
CoNratlor �
� ❑ . . �(�_- �
I am exempt under Sec. �' }^�!,� v+
Plan check fee "` �
w
e.&P.C.for this reason PERMlT ISSUING FEE$ �:4�-��"�'� �
Date:
Signatu�e TOTAL FEE
OWNER-BUILDER DECLARATION NtAN criECK aPvuCaNr -
I hereby affirm that I am exempt from ihe Coniractor's License ► . � �
� Law for the following reason (Seciion 7031.5, 8vsiness and Na�vte � . �
Professions Code):
❑ I, as owner of the property, or my employees with A�DRESS .
wages as Iheir sole compensation,will do the work and CITY TEL NO. � � � �
the structure is nof infended or offered for snle(Section J
704d,8usiness and Professions Code). � i � �
OWNER �
❑ I,as owner of the property,om exdusively contrading ,
wiih licensed coniradors fo consiruct the project(Sec- - MAIL
- tion 7044,Business and Prnfessions Code). A RESS -
CONSTRUCTION LENDING AGENCY i ��. J? ip.Np. - �- - .
I hareby affirm that there is a conshuction lending agency for � ' "� . ' � � . -
the performance of fhe work for which ihis permit is issued �pNieA • ,-
(Sec 3097,Civ.C.). %�� / - � . . . . .
� � ' . ADDRE. -. _ .._ . _
Lender's Name
fT �a EL.N
� Lender's Address � "� .
STATE L` ,�, LIC.
I certify ihat I have read Ihis opplimtion and state ihat ihe LICENSE No. �-� CiA55
above information is mrrect.I agree to comply with oll County
ordinances and State laws relafing lo b�ilding consiruction,
and hereby auth riz r pr entatives of this County to eMer � � ��� �-�- _ � � � --
� upo the obov � n�pert for�Po 5 SEE REVERSE FOR EXPLANATORY LANGUAGE
JSignW'ure of Applicant or Ageni �ate � � - --_
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