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1402A
WORKERS COMPENSATION DECLARATION p nn� ��w T�i1w1 �Ao �C��AIT �i I � F hereby'af{irm ihal I hnve a certificate of mnsenf to self I9l�� i.ii.ii i i�iV ���� i�iiiVii i � ;�S,,,P,o,a�e,,�r��are of wa�ke�s comPe�s�r�a�in5��a�,«, HEATING - VENTILATING - AIR CONDITIONING 'ar a certified mpy thereaf(Sec.3600,Lab.C.) � 7[J�:i6aC ��y- y ��� CE A18(RF.V.10/B1) , PolicylyrS`c.'f���/2�/�oinpany,.T„�L'��'�L=(t-� � Certified copy is he�eby tumished. COUNTY OF LO$ANGELES BUIIDING AND SAFETY �Certified copy is filed with the county building inspeo- fOR APPLICANT TO FILL IN Ruu.ow� �" u i J` j �/,�..{' tion de a tment. ADDRE55 „j - < �_�.�¢. y -x..' 'J' �-.. / Py����.// (PRINT OR TVPE ONLY; �(�- j'_� Date/ ����°'a Applimnt,.�� .._±� --- -- --'— tOCALITY�+i'L7—TL�.S�� '' �._ �." h'O. ?YPE OF APPtIANCE OR EC;U;PMEN? fEE CERTIFICCOMPENSATION�INSURAN EORKERS' --- CROSSSST, �dj,�� ,f-- ftj,asZy�}z� S�� (This section need not be completed if The work involved by A�SORPrioN uwT,BTU o�sreicr No vuoccssm ur the permit is for one hundred dollars(5100)or less.) � AIN HANDL'NG UNIT,CFM r-�� I cerlify thot in ihe performonce of ihe work for which�his ------- � � 1 � 1 Z:{,, U�1�-- � permi�is issued,I shall not employ any person in any manner gpi�ER,giu 1 so os to become subject io�he Workers'Compensation Laws. _ ___.___...._ nrruovn�s on�� �Nsrecroa's s•cNniuu� ; �- ��r r...�'a� ----- � COMPRFSSOR,fiTU'__��d �` -�"'� ROUGH—'___'_ '� Gs�--.---.— Date Applicant — � iJOTICE TO APPLiCANT: If, after makiny inls Certificate of p VENiiLATiON SYST2N� �INAI 1��/{� i�"�—� Exemption, you should become subjec! to ihe Workers' �-- ��- - Compensatian provisions of ihe Lnbor Cade,you must forfh- PVAPORATIVF COOLFe I VALIDATION � m�i±h con!ply •xith such provisfens o! !his permit shull be __ ._— � doemed revoked. FURNACC hAU G LI7Y LICENSED COiJTRACTORG p'eCLARATION �`'�UUN —`���. "�' � � I hereby affirm that I c�m licensed under provlsians of Chapier 9 HEATFR- Sl15oENDED _UNIT_ (commenr.ing with Section 70D0)of Division 3 of ihe Business wA��. �, � and Professions Code,and my license is in full 4orce and effer,t. � �` ,p, �� ! c�� F C1. ; 1,� ' / ' !� .J �1.��r1"...../'s(` ��. '_ � . �'j i— ---- �t � : License Nurnber �`� Lic.Class�—� ' �� , : � r E ,:, 1 �? n . e _. `' �,r,��(� y�/ .J�'1.,f!Lr ___.. ...._— ___.- _ �5 y: Coniractor t �""''�'W`-- � Date • �' (J � i e e .. . ....�. � � ❑ I am exempt under Sec ---'— - � Plcn check fee y • ,.,. _ . .-. � d 6.8P.C.for Ihis rea5on --.... - -- . , , . ,. PERMIT ISSUING FEE S �� ,�1 ' ^ � Date: __. `r,. `� � _. Signature ----- --- TOTAL FEE 'J .� �-.d� OWNER dUiLDER DKLARATION Fl,w c4�{Ec�c APPucANi � I hereby affirm that I om exemp�irom fhe Contrador's Licens� ----- � law for thc followiny reuson (SecYion 7031.i, F3usine,s and NAM6 � Professions Code): , ❑ I, as owncr of the prnperty, or my crnployees wifh AUURESS ' wages as iheir wle compensaiion,will do the work qnd CITY fEL.NO � �he siruUure Is not intended or offered tor sale(Sedion _ i 7044,8usiness and Profes�s�ons Code). �7 , OVJNER ✓`� � ,��� � ❑ I,as owner oi the property,am exdusively mnfracting � t �� — � MAIL ��" /��� I with limnsed mnirnctors to construd the project(Seo- qpURFSS ,.�_� l �/!� l,X.[, /%�'�_ � tion 7044.6uslness and Professions Code). CONSTRUCTION LENDING AGENCY '�"' I I hereby atfirm ihat�here is o conslrudion lendiny oyen�y for �ITY C�y ��.e„� ��C.�� f4 NO 'G)�"'L;C.w� I the performance of the work for which this permit is Issued �UMRaCiOR �j �-fjY' , (Sec 3097,Ci�.C.�, A��RF55 �� + I Lender's Name . ' ��v'rf/z'�a:4'r J��.. � ciTv s�°'y.y,z�--_ TFi No `�J?l:—(,J'Y%�.'�. Lender's Address � I cerhfy ihnt I have reod Ihis appiicarion pnd sio�o thot ine STATC t /i f! /�l;`p IIC �",�� LICEN51 NO- "7 � ..� C1A55 �� above information is corred.I ayree to comply with all Cnunry i ordinanms ond Sinte laws relaiing io building construction, Iond hcreby authorize represrrdotives ol�hls County to enter upo> e cbo� -ment�oned property for inspc��iion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ! ,��1 ���� � �-�S'=�°� , � Sl�rnnr nr Agrni ��n�� �1 ,1 ! � 1 � ` � ,1 l` 1 j , S .1 '1 ,1� .,' ,11 ' �; '� . .... � !� , �� .. 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