HomeMy WebLinkAbout1401A (7) WORKERS'COMPENSATION DECLARATION A 11�f1 1/�A TIA�Y �/1� �C�AAIT �
I hereby'c�firm thot I have a certifimte of consenr to self AFf LI�.A�IV�\ 1 Vi� i�Riiii i j�
ir:sure,or a certificate of Workers'Compensation i�5��a���e, HEATING - VENTILATING - AIR CONDITIONING ��
� or a coriified copy thereot(Sec 38D0, ;b.C.) 76A364C
� ❑ Y , g �/ ^7 p Y���� CF 818(KEV.10iA1)
Polic q��l� ��om an ��6�7 �'
Certit'iad copy is hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is fled with the county build�ng inspec- FOR APPLICANT 70 FILL IN awiowc�•�7 �^ / { `�,r t /�
` � ADURES$ ,J (--��'.. n-• L,,,/e��
tition depa�r"i,m:�ent. _,__ �1 �� (PRINT OR TYPE ONLY) -
Date1J—L_[l.�Applicanr � ,f�^�/Zt.� / � '� ��— -- --- --- iOCAUTv��/ L��//y�,��/r.- �
NU. fYVE OF ANPLIANCF OR EC�LIPMfNT �EE /('� �~ `-` " a�
t CERTIFICATE OF EXEMPTION FROM WORKERS -_-- NEARES' y 'j�,����a��"
' COMPENSA710N INSURANCE CRoss sT. ��'I1 , J-"" -��
° ABSOKPfION UNIT,BTU
(This secTion need noP be completed if fhe work involved by _ _ o�srxirr n�o vuouss�o ov
", the permit�s for one hundred dollars(5100)or less.) � `
4 I certify that in ihe performance of ihe work ior which ihis A�R IIANDLING UNIT,CFM y 1
� l�G+..\o'�'�r-
`
permit is issued,I shall not employ any person in any manner gpILER,BiU
�' so as to become sub�ect to ihe Workers'Compensation Lnws. arreovnu onr� wsaiciou's sicanTueF
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� Dofe Applicanf �` COMPRESSOR,8TU _`_ __ �U RDIIGH � ��"'"
NOTICE TG APPLiCHNT: If, after makiny ihis Certificate of "� Vf.NTILATION5Y5TEM FINnI ��(,//� v+ _
t Exemption, ycu should become subject ro ihe Workers' I
j Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOIFR t VALIDATION
� v✓ith comply with such provi<_ions or ?his p=rmi? =ha!! be .. � /�, __�
� deemed�o�okod. � • ruRNncE� Fn�__cR�vn� .�� /� -
LICENSED CON?RACTORS DECLARATION f;00R _B1U
� I hereby affirm that I am licensed under provisions of Chapter 9 HFATER: SUSPf NoeD _UNIT
t (mmmencing with Section 7000)af Division 3 of fhe B�siness __ _ �'`'�'-'•— , a..
� ond Professions Code,and my license is in ful�force and effect. �� ,/ ._�r��/ —I+�)^7.r- I �
/�� C 3✓ L�,L / , n
� License Number ,���� Lic Closs��"7 ��� � '�� �� ' �
"� er `� r'� t — -- ► ,- w r a � , �
j Coniractor �'��V`�1'I /Dote� l � �
� ❑ I am exempt under Sr,c___ ---�-- -- i e � ,,,,`,:��j �
; Plcn check fee _ p,
s 6.&P.C.for this reason . .... .. --- --- . �: -': � .r „___ � �
PERMIT ISSUING FEE§ C3 a � }
3 --_ Date: ."'_ f;i;1;�� i._,. r ...
� � TOTAL FEE ` �� •'�S
� Signalure '
� — i
OWNEH-BWLDER DECLARATION F�Hrv ctiecK nP�ucnNi
� I here6y affinn thql I am exempt from ihe Confractor's License ,
e iow for the following reason lSeUion 7031.5, 6usiness and NAMC
� Professlons Code):
❑ I, as owner of ihe oroperty, or my employees with ADDRESS
� woges as their sole wmpensation,will do ihe work and �iiY TEL NO.
ihe struclure is'not intended or offered far sale(Section
j 7044,Business and Professions Codel� /�
� ❑ OWNER , %�P�''�.fC.,�E.�'�.r-''^__
I,as owner of ihe property,am exclusively coMracting �
wiih licensed rontracfors to construd the project(Seo- MAIL � ;� i `�.
tlon 70dd,Business and Professions Code�. ADDRESS l�I�(J �/`���
� CONSTRUCTION LENDING AGENCY ��ry �� �M :J-�� TEt O, �'�{,`�J
� I hereby affinn ihat ihere is a construction lending agency ior ��
� }he performanr.e of ihe work for which ihis permit is issued CONTRACTOR y���y,� .�/
(Sec 3097,Civ.C.). �,_ " ".."" �J�" '
AD�RF.55 -
� , fd,!`�L/1��''c�'
Lander's Name_
� CIiY - '' ' TEL.NO."'^� {�
� Lender's Address �' � �"�"� ��( � "� ���
0 sTnr� i/ [ `,'��r i: i ic /',.-)�.
� I certify fhot I hnve read this opplirniion and srate thof Ihe LIC1 NSI NO �- L( ._��"I CLA55
� obove intormution is correct.I agree to mmply with oll Counly
i ordinances and Sinic laws reluting io 6uilding construction,
` and hereby outhori�e representqflves of ihis County to enler
� upon+ a6ov mer�tioned properry for inspectinn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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