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HomeMy WebLinkAbout1194A WORKER$•�oM�NSAT�oNOE«ARAT�oN , - APPLICATION FOR PERMIT I hereby affirm that I hvve a cerrificate of consenl to self � insure,or a certificate of Worke.s'Compensation Insurance, - - HEATING - VENTILATING - AIR CONDITIONING �' or a certi(ied capy thereof(Sec.3800 Lab.C. 76A36aC � �� . � CE-818(REV.10/91) �P❑olicy No.(��C{�d{fY�-ompany + COUNTY OF LOS ANGELES BUILDING AND SAFETY Certi(ied copy is hereby furnished. � � Cerli(ied copy is filed with Ihe county building inspec- FOR APPLICANT TO FILL IN � BUIIDING Da�e�fion d parlmenL (PRINT OR NPE ONLY) P.DORE55 I L3—Applimnt IOCAUTV � � NO. TYPE OF AGPIIANCE OR EQUIPMENT ' FEE CERTIFICATE OF EXEMPTION FROM WORKERS' � NEARESi � COMPENSATION INSURANCE CRO55 ST. (This seclfon na�d not ba completad if}ha work Involvad 6y Ag$�RPTION UNIT,8TU DISiRiCI NO. PRO[ESSED BY }he parmif is for ona hundrad dollars($100)or less.) qIR HANDLING UNIT,CfM �I[ertify Ihat in the performonce of ihe work for whith ihis � ' Q � _ permit is issued,I shall not employ any person in ony monner ' so as to becoma subjecl to the Workeri�omPen5011on�aWi. BOILER,BTU APPROVAlS DATE INSPECTOR'S SIGNATURE — Dafe APPlimnt . . COMPRESSOR,BTU 1 Q� ROUGH � ,� _(�� /� NnT�CE i0 APPLICANT: If, ofter making this Certificale of VEMILATION SYSTEM - FINAL � � . l b�ion, you should become subject to the Workers' � C�...bensalion provisions of�he labor Code,you musl forth• EVAPpRATNE GOOIER NALIDATION wilh comply with such provisionz or ihis permit thall be deemed revoked. ' � FURNACE: FAU_ AVI LICENSED CONTRACTORS DECLARATION 1 Fi00a eTU � ' I he�eby offirm tha�I am licensed under provisions o(Chapter�9 HEATER: SUSPENDE� UNIT_ . '(commencing wilh$edion 7000)of Division 3 of�he Business ' WA« - and Professions Code,and my license is in full force and effect. } �'�(tVA^X"�� a . License Numher'�L�Lia Class • - , . V a �Con�rocto� Dole � - . . . . . . � ❑ �am exempt under Set. � . .. _ . . w Plan check fee N 6.8P.C.for this�eason PERMIT ISSUING FEE S "� ? . Date: Signa�ure TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT � , I hereby affirm ihol I om exempt from 1he CoNractar's License�- � law for�he iollowing reason(Sec�iorc7031.5,8usiness and r,n�ne . - . � � �1 1 9.4 A � Proiessions Code): - � �ll, as owner of the property, or my employee5 with ADDRE55 �� �tr � �8 � ._J wages as their sole mmpensa�ion,will do�he work ond � the structure is not imended or offered for sale�Sedion ON � . iEL.NO. . � ++4 9,7 5 � 704E,Business and Professions Code). . OWNER � ' �� �t19,7 5 c=.o ❑ I,os owner of Ihe property,am eaclusively�comrocting with licen3ed cantrac�ors to consMuci the project(Sec- ��� lion 7044,Business and Proiessions CadeJ. /oDRE55 1 �a z 5�8(� CONSTRUCTION LENDING AGENCY - � Citt � � ieC n10. � �- ---���� I hereby afiirm that there is a consrruuion lending agency for ' , - ihe erformance of the work for which this ermit is issued r'' P P CONTRACTOR � (Sec.3097,Civ.C.1� : . ' . . . ADDRESS .� � � --�.. . . Lender's Name . OTY . / TEL NO. . . ._ ._ .. _ lender's Address . � STATE /r/�,p�7 IIC. /� � � I tertify Ihat I have read this applito�ion and state thot the LiCENSE N0. � v�"I p Q �lASS l..i� � �� ' � -�� � . . . . . . obove in(ormotion is correct.I agree to comply wi�h oll County , ordinontes n la�e lows relo�ing to building conzVuUion, � � � ond he eb� t orize representatives of this Coonty�o en�er - � � � � � ���� - �- - - - -�- - --�-----"� - opon t , o - rioned property for insppeai n purposes. 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