HomeMy WebLinkAbout1617A (9) ,WORKERS'COMPENSATION DECLARATION App�ICATION FOR PERMIT � ��
I h�reby affirm �hal I have a certificate of consent to self '
insure,or a certifimte of Workers'Compensation Insurance, �6A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereot(Sec.3800,La6.C.) CE-al8(REv.ioie7)
P❑ol�icy No.�6���h.z���Company S7ATE FUA/�7
Certified copy is here6y fumished. COUNTY OF LO$ANGELES BUILDING AND SAPETY
� Certified mpy is f�led with rhe mu�ry building�nspec- FOR APPLICANT TO FILL IN Bu�towc,
tion department. (PRINT OR TYPE ONLY) P.DDRESS �7zy ]�fJ 1�Ai� C'�Q�'"E�[ /'ZC�
oare_7lrf�x� qpp��ca�r� �t. . �ocnurr (j/�1Mo/�'lJ E3R/Q
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FRO� WORKERS' � NEnREST
COMPENSATION INSURANCE CROSS 57. �FI.I�IDL�D �RNL�
(This a�cfion need not be completed if the work involved by ABSORP7ioN uwi,eiu oisrzicr No. veotesseo ev
the permit is for one hundrad dollars($700)or less.) /�
AIR HANDLING UNIT,CPM �
I certify ihat in the performance of the work for which this -
permli is issued,I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Lawa e0i�ea,Btu nPPaovnts onre iNsveaoa•s si�Nnruae
Date Applicant CO/v�PReSSOR,97U ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of vErvti�A7iON5YSter,n FiNA� ,�' '� �J--
Exempfion, you should become su6jed to the Workers' .
Compensa�ion provisions of the lobor Code,you must forth- EVAPORF�TIVE COOLER YALIDATION
with comply wifh such provisions or this permif shall be
deemed revoked. FURNACE: FAU-GRAVITY �
IICENSED CONTRACTORS DECLARATION FLOOR B7U
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT__
HEA�ER: yyqLL
'(commencing with Section 7000)of Division 3 of the 8usiness
and Professions Code,and my license is in fuli force and effect. �'
0.
! SPA tfFArEP. -!z5 art� 6T(� 07l p
License Nu SUNS'UM1/�+ Z� Lic Class � - �
Contractor t7E V �CONST�E' Date �� � � O
❑ 1 am ezempt under Sec W
Plan check fee a
6.8P.C.for rhis reason- � -
PERMIT ISSUING FEE� 1� z
Date:
Signature TOTAL fEE O �Z�
OWNER-BUILDER DECLARATION P�aN Ct+ECK APPLICANT � -
1 hereby affirm�hai I om exempt from ihe Contractor's Llcense , . �-C �y�/
Law for the following reason (Sedion 7031.5, Business and NAME �.1
� Professions Code): 1�"`y�
❑ I, as owner of ihe properly, or my employees wiih AODRESS �•
wages as iheir sole compensation,will do the work and �
the siructure is noi intended or offered for sale(Section CITY TEL NO. �� �,'� �R
7044,Business and Professions Code). �
❑ I,as owner of the properiy,am exClVsiVely[onirading nWNFR RlC.fi�A�f� . �-0 N Y�/4°� �`,e • •'• •8
with licensed conlractors to consirud ihe project(Sec '�'�A�� �j d / � � ��Q 5(}
fion 7044,Bu5ine55 and Professions Code). A�ORESS 2��7 ���1�/u L�R�tt�' �f/
CONSTRUCTION LENDING AGENCY CItY A���Q�y p �A� TEL.N .Ir(,y �(�r-� S� e o o�
I hereby affirm that ihere is a constr�ction lending agency for �'5�~
the performance of the work for which this permit is issued CONTRACrOR S J .soNG �E� GONS`T , � �_��"8 5
(Sec.3097,Civ.C.).
aooaess ��53 CL19RENoNr' L
Lender's Nome �
Lender's Address CITY D��Q�� TEL.N .7t� 6 .�_� A�
� fi
STATE e� LIC.
I certify 1ho1 I hove read Ihis applicotion and state}hat the LICENSE NO. ��Cj�Z,/ CLA55 �
abave informafion Is correct.I agree fo comply with all Couniy .
ordinances and State laws relat�ing to building consYruction,
and hereby autharize representatives of ihis County to enter
upon the above mentioned propeny for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �
� Signotvr�� Appl�imnl or A__� {rDate '
�
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