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Home My WebLink About1283A (6) WORKERS'COMPENSATION DECLARATION � � 1 hereby aff'mm thal I have a cer�ifitale of consent to 5e�r . APPLICATION FOR PERMIT insure,o�a cerrifico�e of Workers'Compensotion Insu�ance, 76A3eaC HEATING - VENTILATING - AIR CONDITIONING • or o certified co/py ther�e7of Sec.3800, b.C.) � CE-818(Rev,l0iat) O�Y�! �/ m��y !� Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certffled copy is filed wirh the county building inspec- FOR APPLICANT TO FILL IN BUILDING � /}�,, � ti n deparlm nf ADDRE55 � U � /,�//�// �PRINT OR TYPE ONLY) y}��/ D6�e / /� Applicant��—,f� LOCAUN f'r �f� � �/ NO. TVPE OF APPIIANCE OR EQU�PMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �(� ' r � � COMPENSATION INSURANCE GROSS ST. `j,rY � �/yJ/�jc��( ABSORPTION UNIT,BTU (Thte sxflvn naad nof bo eompl�bd IF}ha work Involvad by onreier Ho, vRocesseo er Ml�o p�rmi}is for anu hvndrad dollorf(SIDO)or lass.) � AIR HANDLING UNI7,CFM I cenify that in the performonce of Ihe'work for which this , 1� m� _ permit is iss�ed,I shall not employ any person in any manner � � — so as to become subject to�he Workers'Compensotion laws. BOitEa,BTU �nvarrovais DAiE MSPECTOR'S SIGNF7URE � Dote - opplitont - COMPRESSOR,BN ��/�DO ROUGH �S P CCtr.:) NOTICE TO APPIICANT: If, after making this Certi(icote of VENTIlAT10N SYSTEM . FINAL- .2—j�� Exemp�ion, you should 6ecome subject to Ihe Workers' � Compensalion provisions af the La6or Code,you musf ferth- EVAI`CRAiR'[COOLER VALIDATION " with comply with such provisions or this permit sholl be � deemed revoked. � . � /' FURNACE: . FAU T JM � � LICENSED CONTRACTORS DECLARATION � ( ROOR BTU /V I hereby afiirm�hat I am licensed�nder provisions of Chapter 9 SUSPENDED UNiT_ "(commencing wilh Seclion 7000)of Division 3 of 1he Business HEATER:. WA�� and Professions Code,and my litense is in full force and eifect. } 'l 1 a License Number '` �� Lia Class C—Z(�� . � . .r _ . � � :� L S J A � � V Contractor,�,�(C��Da�e !�^�� .. �• . e e .8 O ❑ I am ezempt under Set. I • •5 1.5 0 W Plan check fee a 8.8P.C.for this reason' � • � •.S.I.J�c=.� Z � PERMIT ISSUING FEE 5 F7 Dote: Sgnarure TOTAL FEE / Sjj 0 n 3 1 —fi 8 OWNER-BUILDER DECLARATION PLAN CHECK APPIICJ+NT . I hereby affirm that I am exempt from the Contractor's License � Law for the following�eason(Sed�on 7D31.5,Bosiness and NANE - . Professions Code); � ❑ I, as owner of the property, or my employees wilh ADORESS . woges os their sole compensafion,will do the work and ihe structure is not imended or offered for sale(Seciion CiTY TFL n10. . 7044,Business and Professions Code). . � OWNER ❑ I,as owner of ihe properly,am eKclusively contracling with litensed tontroUors 10 construci the projec�(Sec- '�^A�� tion 7044,Business ond Professions Code). ADDRE55 //' �U'e. CONSTRUCTION LENDING AGENCY � - p7y /.. EL.NO. � I hereby affirm that there is a construcfion lending agency for �E ihe performonce of the work for which Ihis permit is issaed COMItACTOR �� , � (Sec.3097,Civ.C.). . .. . ..._. ._ . . . . � ADDRE55� �� —' . . . � •. . . . . Lender's Name /,/' . . . CITY ��_ TEL.NO. 3N'Ysy� . . lender'sAddress -� - -� ' �"� � � I tertif that I have read this a lim�ion and sia�e iha�iha. STnTE f ' �/7I' uC. y PP IICENSE NO.'�—(�( c��-G - ttA55 C� � above information is torrect,I ogree to mmply wilh all Counly � �� _ � ordinonces ond Stote lows rela�ing to building construction, . and hereby oulhorize representatives of Ihis County to eMer . . � � - � �- " - " � �� ' upon ihe o �e-mentiqned property for i pection purpose. SEE REVERSE FOR EXPLANATORY LANGUAGE r� ' S�gna�me of AppGmm or Agent Do�e -.- . . -. . ... - . . . � - ---- - _ - _ . :1 ! � � ' � . �, • i - � . , �. . � � _. ' _ - . . - • ! - r, , .� ; . , _ �.i• � ... , ; . �t�: � . • .. .� ,� ' Z �� . � _— - .,. , , � v+ �•� '', . � _ m � " ' . t „` • . A , „ • _ ' . N _ � • ' ' . ' . . ., . . N ' � � . � . . .. � . . . ' �� ' � ... .. - :-i . " .. .- ._ _ " . . i . • _.. ... . _ _ . � .. i . . . .. ....- - -� - .. .. ., • - . r , . , �� .. - � . ... •- t , .. • ! ' ,. ' � � . � . �i. . .. ; ' _ _. . � � . ,1 w • . '- •r ''.. . " 1 � .1 ` � '�� , ;�� i � . N �� .. , � - � � 1 . 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