HomeMy WebLinkAbout1662A (9) WORKERS'COMPE�4SAilON DECLARATION . `-��� �
I hereby effirm tha��havelo cenifica�e of consent lo,e�f � � APPLICATION FOR PERMIT �
i�su.e,or o ceriificate of Workers'Compensotion��so�a�ce, . �HEATING - VENTILATING - AIR CONDITIONING
or a certified capy thereof(Sec.3600,lob.C.� 76AJ6aC � . . .
CE-818(RFV.10/81J -
V❑olicy No. Company �
Certll�ed copy�s hereby furnished. COUNTY OF LO$ANGELES BUILDING AND SAFETY
� Certified copy is filed wiih the munty building inspeo- FOR APPLICANT TO FILL IN BUItDiNG !�2 Z l G` •
tion deparimenl. (PRINT OR TYPE ONLY) � ADDRE55 oc J
Date Applicant LOCAlI7Y�C� ��
NO. TYPE OF APPIIANCE OR EQUIPMENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � � a� `��
COMPENSATION INSURANCE � CeoSs si. �
(This ssefien nesd not bv complofad if iha work involved by ABSORPTION UNIT,BTU OISTRKI NO. GROCESSED BY
' 1he permi!ts(or one hundred dollors(5100)or less.) t O �,(' _ `�-�
I certi(y 1ho�in�he performance of the work(or which this. AIR HANDLING UNIT,CFM �, ��
_ � permit is issued,I sholl not employ any person in any manner BOIIER,BTU --
so as to ecom subjed�o ihe W k rs' ensoiion L S. APPROVAR onTe INSMC70R'S SIGNATURE
'1O �� GOMPRESSOR,BTU O�O ROUGH
Date pplicaM . .
NOTICE AP LICANT: If, aRer making fhis CeNificale oF VENTILATIONSVSTEM iINAL � QOS
Exemption, you should bemme�sub(ect to the Workers'
Compensaiion provisions of the lobor Code,you musl forth- EVAPORATIVE COOLER VALIDATI�N
with comply wNh such provisions or this permil sholl be
deemed revaked. � FURNACE: FAU ' RAVITV .
- LICENSED CONTRACTORS DECLARATION . FlOOa ��eTU 0
I hereby affirm fhot I om Iicensed under provisions of Chopfer 9 NEATER: SUSPENDE� UNIT- �
'(tommencing wiih Section 7000)of Division 3 ot ihe Business wA0.
and Professlons Code,and my license is in full force ond effect. � . . -" � O
lkense Nu ber ����� Lic Class� �v �� /� . 1 C, , V
�QS��n �
Contractor n Date 5�31� �
❑ u
I om ezempt under Sec. d
Plan check fee ,�
8.8P.C.for this�eason pERM1T ISSUING PEE S �(�j (`. ?
Da�e:
TOTAL FEE *�(p�1
SignaNre
OWNER-BUILDER DECLARATION MAN CHECK AavIKANT �
I hereby aifirm thot I am exemp�from ihe Con�ractor's license �
Law for the following ieason(Sedion 7031.5,Business ond NnrnE �
Professions Code): �
,❑ I, as owner of the properfy, or my employees with
AD�RESS
- wages as their sole compensation,wJl do the work and CiiY Te�.r,o. �1 6 G 2 A
Ihe str�cture is no�intended or offered(or sole(SeUion
7044,B�siness and Professions Code). OWNER �� � � � �$
❑ I,as owner of 1he property,am exclusively con7rocling �l �~
wiih licensed conhac�ors to construc�the projett(Sec- �"�'�� � �� � ' •7 6 2 5
tion 7044,Bvsiness and Professions Code). � ADDrtE55
� CONSTRUCTION LENDING AGENCY � �iTy� �, w TE�.N �v • • � �C��5�
I hereby a(firm Ihat there is a tonsfruction lending ogenty for
ihe performance of the work for which this permi�is issued �pNTRACTOR m� - " � � - " , a 9,2 0—fi 8
(Sea 3097.Civ.C.J. - . • .. . � . . . -
ADDRES$ V L' � -- -- - ' -'
Lender's Name ,
CITY ' . TEL NO. � .'_.. . .... . _. ._ . .
lender's Address �
STATE LIC.
I certify that I have read rhis applica�ion and state that fhe LKENSE NO. C�ASS�- -� --�� -- �-- - -- � ��-�- �-��� �- - -
above information is correcf.I ag�ee fo comply with all County ,
ordinonces and S�ate laws reloting�o bvitding constroctian, . . . . _ . . .. . .
a here tho�ize re resentalives of t is County fo eNer - � .
' o th 6o e-menti ed property(or i speU' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
$'gn �ure of Applicanr or Ag�i �e
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