HomeMy WebLinkAbout1305A (7) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
" nereby affvrm t;iai I have a cer�ificate of consent�o self
insure,o.a cer�ifimte of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a ceriified copy ihereof(Sec 3800,Lab.C.) 76A364C .
¢ �+ - n r�CE-818(REV.10/Bl) '
P❑olicy No.�"� �� ����✓��o'm�any�LCL���7i:�E�J��7S y�✓��`L!'`
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county 6uilding inspeo- FOR APPLICANT TO FILL IN eu��DING ( - �1
tion depa tment. a�oaess � �� 6 ��j�� � c'G'. �)�
J( �.� j�, � � � (PRINT OR TYPE ONLY1
�` Date�j'�d f Applicant . - r.��/ LOCALI7Y �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �a�d�� u�
CERTIFlCATE OF EXEMPTION-FROM WORKERS' NEaReSi �
COMPENSATION INSURANCE CRO55 57. J'�':� .„� - r:
A850RPTION UNIT,BTU oISTRIC7 No. ItoCE55ED Bv
(7hts section need nof be completed if the work involved 6y
The permii is for one hundred dollars(SI00)or less.) -
I certity that in the performance of ihe work for which�his AIR HANDLING UNIT,CFM ��
permit is issued,I shall not employ ony person in any manner
so as to 6ecome subject to the Workers'Compensation Laws. BOI�ER,BTU APPeovnis oare iNsa�T e's sicnnruae �
Date � Applicant � Conn7ee55oa,siu �d- ���� �J t'✓ ROUGH _
NOTICE TO APPLICANT: If, after m�king this Certificate of vENTILATION SYS7EM ��NA� r—��", „+'
Exemption, you should become s�bject to fhe Workers' -- �
Compensation provisions of ihe La6or Code,you musi farih- EVAPORAiIVE CWLER VALIDATION
wi�h mmply with soch provisions or this permii shali be
deemed revoked. / FURNaCe: FAU GRAVi1Y_ %� � �
LICENSE�CONTRACTORS DECLARATION f FLOOR BTU �1i'v
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDE� UNIi_
-(commencing with Secfion 7000)of Division 3 of fhe Business HEATFR� y�qLL
and Professions Code,and my license is in full force and effed. ,' p� � ,p,,.= � ?7 �U,Jr h �
{� C.r-Ge�G 7tiL.0�C d
License Number L •�e L" Lic.Class�_ ► #e • • m •8 �
Contr�ctor�G��51/bi. �Dofe_��_ �
1 � +47,C0 A
� aa ~
I om ezempl under Sec. �� �,�U'1? w
Plan check fee b
Q4,02—��7 �
e.&P.C.for this reason pERM1T ISSUING FEE j �t3 Q
Date:
Siynature� %'��' TOTAL FEE
� OWNER:BUILDER DECLARATION Pi.4N CHECK nPvuCANi � . - � .
I hereby affirm ihot I am exempt from the CoMractor's License , �
Law for the following reason (Section 7031.5, 0usiness and NAME _ — - �
Professions Code):
❑ I, as awner af fhe proper}y, or my employees with ADDRESS �
wages as their sole compens�tion,will do fhe work and
the structure is not infended or offered for sale(Sedion CI7V TEL NO.
7044,Business and Professions Codel. �
OWNER �.i�?j'j�.
. ❑ I,as owner of�he proper�y,am exclusively mnhacfing
with licensed conirodors to consfruct the project(Sec- MAIL "'� �
fion 7044,B�siness and Professions Code). .400aes5 �i �J`�C ��{
CONSTRUCTION LENDING AGENCY . CiTY � TEL.NO. �
- I here6y affirm thnt there is a construtlion lending ogency for �"!nP/J6 � ►
the performance ot the work for which this permit is issued CONTRACTOR -
(Sec.3�97,Civ.C.). ��
a��Ress � "L T G
Lender's Name
Lender's Address CITY e1-,�;Lf� TR.NO.` �S-� �
5TATE LIC. '
I certify ihof I have read ihis opplicalion and state}hai the LICENSE NO. �� C�. CLA55 ' �.
� a6ove-informarion Is corceci.I agree to comply with all Counry
ordinances cnd State laws relating�o building construdion,
and hereby ouihorize representatives of this Counry lo enter - �
upon,�lhe�e-mentioned property for inspection purposes. SEE REVERSE fOR EXPLANATORY LANGUAGE
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• �Signature of Appliconr or Agenf Dote
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