HomeMy WebLinkAbout1418A WORKERS•�oMPENSAT�oNOE��,aAT�oN - APpLICATION FOR PERMIT � �
I hereby affirm that I have a certifitate of consent to self
inw;e,orw certifita�e of Workers'Compensmion Insoranca, - H AT VENTILATING - AIR CONDITIONING f
dr a certi(ied co y�hereof($et.3800,Lab.C.) 76.496aC .q �j' ��(
�y . CE- 18(REV.10/Bl) a L�-M d'V.
a�UlNo �1�0� Compono��l�Q�flO� �,Q`�-e� .�� `� r ' � CO�QE�-� ��!�.i>� ���s�'u. —'--
Certified copy Is hereby furnished. �UILTY90F L � A GELES . BUILDING AND SAFETY �
Ce�tified mpy is filed with the counl building fnspea �� �[�r[ q yr ILL• ry'� BUIIDING /
� „o�d o<< �f. ,u�,p. i_�_�c� .�.� ��qp ,,,[. � i` ., , oS3 .�A5 )
\yI t� t.�.� .,4C��"�I"T�RiT� .�� .iY G�.G� `� ADDRESS �y J
DO�e Appli[ "•, �� N041�TYPE OF APPLIANCE OR EQUIPMENT.' . FEE `�"TM � ` `
C RTIFICJ�TE OF EXEMPTION FROM WORKERS' �� NEAREST
COMPENSATION INSURANCE CROSS ST.
� (Thts sedion naad not bo complaled I(Ihe work Involved by A950RPTION UNIT,BTU' � oiSrciC7 No. Px ._
fhe permlt Is for ona hundr�d dollars(5100)or leu.) . �
I terlify thot in Iha performonce of ihe work for which this AIR HANDLING UNIT,CFM
permit Is fssued,I sholl noi employ ony person in any manner �"`~��
so as to become subject to the Workers'Compensation laws. BOitER,BTU APPROVAIS DAiE INSPECTOR'$SIGNATVRE
Dafe �ApPlicont COMPRESSDR,BTU ��d��7�� ` ROUGH � �
NOTICE TO APPLICANT: If, after mok(ng this Certifitale of VENTiL47iON SVSTEM FiNAI t,{(,"� ��,
Exemption, you should 6ecome subjecl fo the Workers'
Compensa�ion provisions of the Labor Code,you must forth- [yqppRqTIVE�OOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. � � - FURNACE: - FAU_GRAVITY � �
LICENSED CONTRACTORS DECLARATION FIOOR BTU ._� �' p A
- I hereby offiim thal I am litensed onder provisions of Chapter 9� SUSPENDE UNIT • - �
HEATER: WAIL � i(. s e • .g
� '(tommencing with Section 70110�of Divisiori 3 of the Business }
ond Professions Code,ond my license is in f�ll forte and effect. 3 . a
p�� •Ir ��9.2� O
License Numbe���D�S�� ,Lic.Class.�_ < , . � ' lJ
Ctuu(oh A�t E.'�'�tti�nl�x.t�rn� • � •'9.2 5�, o
Controctor D f_
� u�C9-^.° �
I om e.empl�nder Sec. W
Plan check fee a
N
B.SP.C.for this reo5on PERMIT ISSUING FEE s Z
' Date: .
Signature TOTAI FEE
� OWNER-9UILDER DECtARATION � anN cNeCK naaiCnNr � _ �
I hereby offirm�hal I am exempt from the Conhacror's litense �
Low for the following reason(Sedion 7031.5, Bosiness ond NAME . .
Prolessions Code): �
❑ I, as owner of�he properly, or my employeez with AD�RE55 . . _
� wages os their sole compensation,will do Ihe work and
tha shucture is not iniended or o(iered(or sale(Section Cltt TEi.NO.
7044,Business and Professions Code). � .
OWNER
❑ I,as owner of�he property,om eaclusively controUing �
wirh licensed conhadors to constrotr ihe projett(Seo �''°`�� \ � ,� .
rion 7044,Business and Pro(essions CodeJ. � � ADDRE55
GONSTRUCTION LENDING AGENCY � �- ��Ty •1 � 7E1.NO. a�_
I hereby affirm that fhere is a construcfion lending agency for � ` .
the performance of ihe work for whith this permit is issued � [ONTRACTOR � �
(Set.3097,Civ.C.). . ..... . . . .. . ._.._. . . .. _._. . _
-� ADDRESS - . . _ ' '" '�
lender's Nome � � � �� �� ���� �
.. CITY ' ` TEL.NO.� � C� .. . .. ..... . , _
, Lender's Address - -
I certify lhot I hove reod Ihis opplicotion and slate thal the .. �ICENSE NO. - C ASS � �— .. ._. _ . __ _ . . .
above in(ormation is correct.I ogree to comply with all Co�nty
�ordinonces and S�ate laws relating to building construclion, , - �
I � and hereby authoNze represeniatives of this Coonty to eNer� . � - -- - � "� �� � - - �
upon the obove-ment' ed properly for inspectio p poses. SEE REVERSE FOR EXPIANATORY LANGUAGE.
� ' � . . .. . __ _
Signorure of Applicanl or Agent Da�e
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