HomeMy WebLinkAbout1192A WORKERS'COMPENSATION DECLARATION \ ' �
1 hereby affirm that I have o cerlificote af consenl to self APr ICATION FOR PERMIT �
� insure,or a cerlifimta of Workors'Compensolion Insurance, ,bA364c . " HEATING - VENTILATING - AIR CONDITIONING
or a cerii' d copy Ihere (Sec.3 ,Lob. )' �_BiB(Rtv.iD/B�J ' � -- � � - �� . .
Polity N ompony � - �
� Cer�ified copy is hereby fornished. , I: COUN7Y OF LOS ANGELES. . , BUILDING AND SAFETY .
�Cer�ified copy is iiled wi�h the toun�y building inspec- FOR APPLICANT TO FILL�N � auitouvc • �
tion d arlmenl. (PRINT OR TYPE ONLY) ADDRE55 �
Da1e�Applimnt J�(� tOCAIITV '(�' �
NO. TYPE OF A7PLIANCE OR E�UIPMENT �� FEE �
,� CERTIFICATE OF EXEMPTION FROM WORKERS' NE/+RESi �
COMPENSATION INSURANCE - CRO55 57.
(Thts isctlon n�ad nel ba cempl�}od i(fhe work fnvolvad by Ag50RPTION UNIT,8TU DISTRICE NO. CROCESSED BY '
tha pormit ic for ona hundred dollars(SI00)or lass.) AIR HANDLING UNIT,CFM
I tertify tha�in Ihe performonce of the work for which this - �� � ,
permit is iss�ed,I sholl not employ any person in ony monner gpltER,BTU
so as fo 6ecome subject fo Ihe Workers'Compensotion Lows, naacOvnlS DATE INSPECTOR'S SIGNA7VRE -
DotB. - Appliconl COMPRESSOR,BTU 1O ROUGH �, ' �
✓
NnT(CE TO APPLICANT; I�, a�ter moking fhi5 Certificate Of � VENTILATIONSYSTEM FINAL �ZC��
( p�ion, you should become subject to��he Workers'
L_.�bensation piovisions of the Labor Cade,you musl forlh- EVAPORATIVE COOLER VAIIDATION
with compiy with such provisions or this pe�mit shall be . �
deemed revoked. � FURNACE FAU G VI � � �
LICENSED CONTRACTORS DECIARATION - � FLOOR BTU
I hereby affirm that I am licensed�nder provisions of Chap�er 9 HEATER: SUSPEN�ED UNIT_ . �
� '(commencing with Section 7000)of Division 3 of the 8usiness ' �'�'A« . � �
and Professions Code,ond my Iltense is in full force ond effed. / - ��-- �'
,nI a
� License Number B3 Lia Class v � �� � V
l I , p:
Contrador r'� Date � � �- � - - . .. O
u
❑ 1 om exemp�under Sec. �y
Plan check fee a
N
B.BP.C.ior�his reason' PERMIT ISSUING FEE S z
Date:
Sgnotore TOTAL FEE
OWNER-BUIIDER DECLARATION - PIAN CHECK APMICANT
I hereby affirm that I am ezempt from the Contractor i License �
low for�he foltowing reason(Sect�on 7031.5, Business and NAME � - �
Professions Code):
r I as owner of Ihe properfy, or my employee5 with ADORE55 - � �
1.:,_,.e.�s�tie�..�ie�,.,.,pe„��r��,will do tha wwk a�� 2 1 1 9.2 A
the struclure is not inrended o�oifered for sale(Section GTY � TEL NO. . � e�. + � �
70E4,Business and Professions Code). - � $
OWNER r
❑ I,os owner of�he property,om ezclusively controcling �a��li 9,7 5
with licensed contractors�o construct Ihe project(Sec-� ���
� tion 7044,Business and Professions CodeJ. ADDRE55 � s� •�,Q,7 5=
U
, CONSTRUC7ION LENDING AGENCY CiTY� � �- TEL:NO. ��--� - - �� � �
I hereby affirm that there is a construtfion lending agency for , n£i.2 5—8 6
Ihe performance of ihe work for which this permit is issued CONTRAROR � '-' -
(Sec.3097,Civ.C.). � . _
..... . .. ._ .....
aooaess � •,f/' - .
lendei s Name
. CITY .. .TEL.NO. �' . . _ ..
lender's Address � �
. I ceriif that I have read ihis a lication and s�a�e tho�the STATE uC.
Y PP L�CENSENO. ��, O . CLASS � -.. . ._..... .. .... .. ..._...... ._ ..
a6ove informalion is mrrect.I aqree fo tomply with all County , � � . �
ordinances an :State laws reiating to building construction, �
and here y a tForize representa�ives of this C unty�o emer � - � -�� ' � � -: " � - �
upan I a o� r �ioned pr�rty for in��ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
�i
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