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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 ----...-----'!� '' � // �7 d�uu[} ..- - ' ---_. � 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 � j I �-��-1--zr �-Zf�-,�1� � . siqno< r�rP o('qpul�,unr or n� uore i � • ' �11 �. . � . ��i ��,,1 �4 .. 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