HomeMy WebLinkAbout1282A WORKERS-�oMPEN�,T�oN oE��RAT�oN � APPLICATION FOR PERMIT 'I
� I hereby affirm that I have o certificate of consent to solf ,
�nsure,or a certificate of Workeri Compensation Insumnce, HEATING - VENTILATING - AIR CONDITIONING GS
� or a cerlified copy Ihereo (Sec.3800 ab.C.) � ���� , _� , . .
CE•818(REV.10/81)
�cy � ompony � � -
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND$AFETY .
� Cer�ified copy is filed with the county building Inspeo- FOR APPLICANT TO FILL IN BUILDING / ' ��
f'on departm nl. " �7 ^� ADORESS
��� �� (PRINT OR TYPE ONLY]
Date � Applitont /I.L.L�IX � LOCALITY � '7 /
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
- -� CERTIFICATE OF EXEMPTION FROM WORKERS' � NEARESi �"�
COMPENSATION INSURANCE � � CROSSST. P'- /cV-�
(Thls sxtlon nvvd nof bo complvtcd il iho work Involv�d by� ABSORPTION UNIT,BTU p157RICT NO. PROCE er
iho parmit Is for ono hundnd dollon(S1D0�o��esi.� qIR HANDIING UNIT,6M � /1 1
I certify tho�in tha performpnce of Ihe work for which this L� 0. \U ne
permit Is issued,I shall not employ any person in any manner BOiLER,BT�
so as to hetome s�bjeU lo Ihe Workers'Compensa�ion Laws. . �f / avPeovnis oare INSPECTOR'$$IGNATUFE
COMPRESSOR,BTU I ` �� /Q �' ROUGH ��'� �� �t✓
Date epplicant . _ . _.
NOTICE TO APPLICANT: If, after moking this Ccrtifi:ato of VENTI:ATIO��SYSTE:t FINAI -?3O -� ���—
Exemption, you should become s�blecr to ihe Workers: • .
Compensation provisions of the lobor Code,you musl forlh• � EVAPORA7IVE COOLER VALIDATION
with comply wilh s�ch provisions or this permit shall be
deemed revoked. � FURNaCE: �� FAU_ �
LICENSED CONTRACTORS DECLARATION FIOOR BTU � D �
� I hereby affirm thol I am licensed under provisions of Chopler 9 HEATER: SUSPEN�ED - UNIT_ � -
. '(commencing with Section 7000)of Division 3 of tha Business WA«
and Professions Cade,and my license is in iull force and elfett. � /, ��` y
��(�/�1�� (J !� Q
License Number�/ /� �lia Class�_� - � V
Contractor- "^"`""` Dale � � . . - . . . z� C�L fi � O
❑ I am exemp�under Sec. _ . ��• • o " �� W
Plan check fee ' a
- B.BP.C.for ihis reason-
PERMIT ISSUING FEE S � ° °��•�G Z
Dale: _
TOTAL FEE • a��1.5 0�
Signalure "
� OWNER-BUILDER DECLARATION PLAN CHECK APPIICANT � O R.3� —H S
I hereby offirm that I am exempt from the ContraUor's License� ► -
- Law for the(oilowing reason(Seclion 7031.5, Business ond NAME
Professions Code); � . ,
❑ I, as owner of ihe properfy,�or my employees wilh ADDRE55 �
ages as their sole compensoiion,will do the work and�- �ITY 1EL.NO.
� the structure is nol iNended or offered for sale(Section
7044,Business and Profeszions Code). � . � OWNER
— ❑ I,as owner of�he property,am exclusively controcting �� G� 1.�- � _
with licensed coNractors lo construcl Ihe project(Seo- qDDRE55 /�[.C�< -GT
. tion 7044,Business and Proicssions Code).
CONSTRUCTION LENDING AGENCY . CiTY � � TEL.NO�'�/�7j
1 herehy aNirm Ihat ihere is a construction lending agency for �� n '
the performanta of the work for which Ihis permi�is iss�ed �ONTRaCTOR �
(Sec.3097,Civ.C.J. . G/ /'•L.7� ._ . � . - . . . . -....
� A�ORE55 !(D LU /�1P � . ._ ,_ ' .. . . . , �. .
Lender's Nome +j ``
, ' GTY ���� TEL NO.7.3 ^YS 0 . . . ... . . . . .. .
Lender's Address I,
I certify�hai I have read this appliwtion and state that�he LiCENSE NO. `�(�� � CLA55 G�� � -- . _ . . .. . .. . .
obove information is correct.I agree 10 comply with all County ,
ordinances and State lows relating to b�ilding construction, � _
and hereby aulhorize representatives of ihis Counly lo enler
upon�he obo�e-men�ioned property for�nspec�ion purposes SEE REVERSE FOR EXPIANATORY LANGUAGE .
�rYt �,,_ �2 _
�Signature of Applimnl ar Agenl Do1e . . . . . - � . ... - .
.�---- - _ . _ _
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