HomeMy WebLinkAbout1274A WORKERS'COMPENSATIONDECLARATION /y���ICATION FOR PERMIT �
I hereby off�m�hat I have a ceniiica�a of tonsen�to self �
insure,or a certificate of Workers'Compensaron Insurance, HEATING - VENTILATING - AIR CONDITIONING Lti
• or a ce�rt'if.i,e,d y£opy rnthereof(Sec:3800, ab.C.)�� 76A76aC .
❑ y f�^�' ��`/� Company � CE-B18(REV.I Oi81) � - � �
Polic / ����
Certified copy is hereby furnished. COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
�.Certified copy is filed wiih the counry 6uilding inspec- FOR APPLICANT TO FILL IN Bu��oin�G `+� �`� v1e� �„
hon departm f. (PRINT OR TV7E ONLY) aDDRE55 � � J ����
� Dale ��� "ApPlimn LO('AUTY � � ZJ
NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST r "
COMPENSATIONINSURANCE , CROSSST. r,�C!✓✓J/IJlT C
(Thls section n�ad net 6a completed if Iha work involved by /+BSORPTION UNiT,BTU DiSIRiC1 NO. GRp�ESSFD BV
fha parmif Ic for one hundrad dollars(SI00)or Ieia.) AIR HANOIING UNIT,CFM J�'
I certify thot in the performonce of�he work for which Ihis V �Gt G'�e
_ permit is issued,I Sholl not employ ony person in any monner gpILER,8TU
so as lo betome subject to�he Workers'Compenso�ion Laws. ^ ( avvaovais oaTe. wsv[tToa�s sicr+nt�ae
Date Applimnl �� COMFRESSOR,BTU O u0� (/ � ROUGH /D��p ��,4.eJ.S
NOTICE TO APPLICANT: If, ofler making ihis Cerliiicate of VENTIL4TION SYS7EM FINA� _Q
Exemp�ion, you should bemme su6ject �o fhe Worke�s'. -
Compensation provisions oi 1he Labor Code,you musl forth- EVAF02ATIYE COOLER VALIDATION .
with comp�y�with such provisions or this�permil shall ba �
deemed revoked. � - - FURNACE. FAU_G I � �
� LICENSED CONTRACTORS DECLARATION . FLOOe s7U �
I hereby afii�m that I am licensed vnder provisions of Chop�er 9 SUSPENDED UNIT_
'(commencin9 with Sec�ion 7000)of Division 3 of the Business HEATER: WA��
and Professions Code,and my license is in full forc/e�ond e(fed. � `1 2 7'�A a
litense Nomber `��Lic.Class`� � � . � � , i�� � � • �� V
� r� I • •53.25 �
Conhador pole . . . F
❑ I am exempt under Sea � - . , � ��O"��2 J� W
Plan check fee °-
B.BP.C.for this reoson� O H S� -�H �
-- PERMIT ISSUING FEE S (�
Do�e:
Signature TOTAL FEE 'L
OWNER-BUILDER DECLARATION. - PL4N CHECK aaPliC/+Nt
I hereby offirm tha�I am exempt from ihe Contrattor's license � � �
Law for the following reason(Section 7031.5, Business and NMaE .
Professions Code): � - �
❑ I, as awner of the properly, or my employees wilh AD�RE55
- - wages as iheir sole compensation,will do the work and CIN � TEL N0. �
Ihe strucrure is not iNended or offered for sale(Settion
7044,Business and Professions Code). .. -
OWNER
❑ I,as owner of the praperty,am ezclusively coniracling ,y} ,
wilh licensed conlractors to mnslrucl Ihe p�ojecf(SeC- qDDRESS ��� �l 'L�
- � �ion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY � CIN � -'�„�- T .nl0 �r �/
I hereby aFfirm that ihere is o construction lending"agency fo� ' ►
ihe performanca of ihe work for which Ihis permit is issued- CONtRACTOR " - - ��-�-
(Sec.3097.Civ.C.). . ... ... .. _. .... .... . .._. .; .
. � ADDRE55- ��� � �—� . . . � - � .. . - .
Lender's Name -
-- OTY �� . TEL.NO.. 3 J ... . . _ . .
Lender's Address
STATE �/ /� LIC.
I certify�ha�I have reod ihis application and s�a�e�har ihe � � LiCFNSE n70. . 1 Y�K C�nSS ' - �
. .. _. _._. -_-. -.-
above in(ormo�ion is correct.I agree b comply with all County
ordinantes and S�ate laws relating to building constroction, _ � , . , _
and hereby authorize representatives of this Go�n�y�o enter
- - . . ..... ..... ... . _ . .. . .
opon the obov •ment`oned roperty(or inspetuon purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
� S�
Signarvre of A Ilcanr or Agenr � Dore ... . . . . . . .. .. . . . -. .... .
• ___ i ..,._.._ �I�..�....r+��,
i r ' ' I
� � " 1 - �
- i -.. _ � _
� ` y
, �
ee(� �• . . ; � �' . �' � 1 .. .
�i . . . , . . ,'r! .. �..
A • � ' ; .. �. . . ._ . . ^
Vi _ . . .' , . .
Z . .. . ' � � .. � . .
� . / .�_ . I.' �, .' ... ....
: � , � 'i � . � . .
• , . ,
, . . , . � . ;. , ..
.. . ' " . .._._ .. .... _. .._.. ._.:... .. ........ . . . ... .. . . _ ... .. . . .. .. . . '. _ ._.. .._ . .. ,
, ` , . . . . . . _ _., . . . - , . �
�1_..-
� ! '
, i .
- � � � _ . .. . . ._ 1 .
i � ..
� .,
i ' � . i . � - . Z " .
� i.., �
. �;' _ . � . m.
. - -ni
i � i' , O
., _ " •' ,. � . . Z
` � i, • ' ' O
; - � � � w
. - �
, ! _ � _ �" �
� � _ � • ' . . '
�' , ' p v m. - 3-cFo'ino o � 3 � Ff .o'i.�s 0000�• �o3c � � �;; s, :
� ❑ - o � �sN � „ F o �-� o � o a,��.o ,, 4 a �
, f . - iN � o - �a � � o H� �, .N.._ o � � � � � m.
• 1 � - ' . � � . � � � �� c n o`a',❑ c� < �-�T c n o� ❑'�" o-`n o tl� � �.�o 'o �? n �. . .
- � , n x � o _ n t, a a-m q _, ,� ,A., - a-. •o a �. H u �c
� - �;. � � a � a� v£.- �. 3 a 3 a,N r..c' U c� o..�o o' o.� o 0 0 0
' : - o •� � N�'" c�a so ° a" � Q � � q� ° o., o. ��-�'o ov � f » �
, � � - . . �p � p O ��_w .i � O, �p tN N: p ��.��:O��.v..r,��„�� t� � -
� N O �
' . � ' ?- c ' N F � � m � � f '" '�� -.f > > ; ..b b.a T.�,-��. �n N 3. o ° 3 m
_ •. ' �. a I n s� °-H � � < -O a`v °-» ° � ��'�'� �� '� ? ,�, � � so A .
" ' rj.. ..� �'J O � � N �LL 4� � 70 O.ri.k.7< 07 � O.NQ �W
� � :. - ° -. u, . ' n:c '" � �°• o m F $ a° � � m '� � 3:�' �"• o� °� o ° - C .
0 0 0 0 � � a o � -�N c � a� T _v.u o a N a �.� o Q �
• . ' � - � . 7- n � r-? O� '-�' T a o ��-n O �:.�� �
° o n n.o o'� m o�o� �-o o n.a � � �_� wnN T� � ° f m �^ .
� � - ! � � F`-' �v N" o 'v c� �� °'ov"� °�° o�o.. .��o�o o m o�.^._�2� o� ' 7p -
' � ' - ° ? �c '" �� b �° �-�o� o °� �� �.?' �-�_� 3 0 9 D 'o, �
r ' _ �n o N o.K o 0 0 ° � � « �" ° 3 '` �� ° o' � - 'D � o ;, � - '
, . . 'n' �7n$ o._.° °' <bj � nQf, °-�'�.� � osoH' � op , .
- ' : , . - � -. • '. ' .. � j �� O � � o•� �� O�C O Oq p o .j C � � U �a c b; in l] � '� .
• :. _: ' m o � 4 c' x o �. o f � � �i o' 3 3 0' i o 0 0 ,� �. .
' • - • -. . an � -�2 ^ �� 3 ,�Q o� �o T �N �.o-N 3 N ,N.,�,:o � 2 O .
� . .. _ • v o �- �....�v �-�m < � o o ;m n °
� o-N o � T o-a.> > � o n Z .
.. � o � T� �-�c o�.,� • f a.,, a n o � - a> > >
. �a n� o o �v n .o �-,� -s � N '� o �. .
' - • ` � n o oa� . 'o' Qo �, o o ;r c �+m.�� a 3 '� vo
. _. _. � �,b,� o o �?� j c o 3 ,o a�_,'D,.a o F -° o c `f:_„
_ _. � o
0� n n 7 a S p � � � 0 � CJ �O _`. ' S� m S n is,N .
� o ��c c o � �--� a a r � N '^ T m T.