HomeMy WebLinkAbout1275A (6) WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR PERMIT �
I hereby offkm that I have a cer�iiicole of consent lo self
insure,or a cerlificata of Workers'Compensation Insu�ance,. �. - HEATING - VENTILATING - AIR CONDITIONING
' or a cer�ified copy fhereof Sec.3800, b.C.) � 76A36EC
CE-81 B�QEV.10/Bl)
P❑olicy N , �1127 ompony _ COl1NTY OF LOS ANGELES . BUILDING AND SAFETY
Cerlified copy ia hereby fwnished. .
�CertifieP copy is filed wuh�he county building inspeo FOR APPLICANT TO FILL IN euitowG � ` �'� f��
fiOn d� aftmenl � n (PRINT OR TYPE ONLY) ADDRESS �
Da1e � �/ Applicant ��L� IOCAUTY �Z
. NO. 7YPE OF AFPIIAN[E OR EQUIPMENT� • FEE
CERiIFICATE OF EXEMPTION FROM WORKERS' NEAREST � n r y���T N
COMPENSATION INSURANCE CROSS ST. �.(/G1� t /LC�s�
(This sectlon nead not 6a complat�d if�ho work fnvolved by - ABSOaPfION UNir,erU O�S�RICT NO. VROCESSED BV
tha permtf Is for one hundrad dollors(5100)or Iv».) - � � �a I
I certify that in Ihe performance of fhe work for which this A�R HANDLING UNIT,CFM D n e
permif is issued,I shall nol employ any person in any manner gOi�ER,eTU
so as to 6ecome subject to the Workers'Compensation Laws. arvaovnis D/iE MSVFCiDR'S SIGNATURE
Da�e - epplicant
COMPRESSOR,BTU � �� �� ROUGH /p s��
NOTICE TO APPLICANT: Ii, af�er moking this Cerlifica�e of VENT�WTION SYSTEM FINAL Z Z9'� ���
Exemplion, you should become subject to iha Workeri
Compensaiion provisions of the Labor Code,you musl forfh- EVAPpRATIVE COOLER VALIDATION
wilh comply wilh s�ch provistons or fhis permit shall be
cJeemed/BVOkeCJ. ' � - � FURNACE: FAU_GRyV171'� O
� �IICENSED CONTRAC70RS DECLARATION � f�00R eTu Uv
I hereby a�firm ihot I om licensed under pro�isions of Chopler 9 HEATER: SUSPENDED UNIT_
�(commenting wi�h Section 7000)of Division 3 of the Business ' wA« .
and Vrofesslons Code,ond m licanse is(n full(orce and e(fect.�"" � }
V�/(/-7 Y /' �s r d ZZ g
License Number I'To J� Lic.Class�_ .. . . . . . . �� 2 7�A V
� z� ► �
Contratlo �� Date /��✓ � . . . �• : • e •$ �
U
❑ I am e.emp�onder Set: Plan[heck fee I • •5�G S a
B.BP.C.for ihis reoson " PERMIT ISSUING FEE S (7 • • "5��2 5� ?
Dote:
S�gnature TOTAL fEE r3 Z 0£3 3 1 —8 8
OWNER-BUILDER�ECLARATION PLAN LHECK APPLICANT
I hereby affirm tha�I om exempt from ihe Conlracror's License �
Low for the following reason(Section 7031.5. Buziness and NAME '
Professions fode�: � � � .
❑ I, as owner of the property, or my employees wi�h AD�RE55 .
� wages as their sole compenso��on,will do the work and CiTY tEt.N0.
the srructure is not intended or offe�ed for sole(Section � '
7044,Business and Professions Coda). . � - � � �
OWNER
❑ I,as owner of the property,am ezclusively contracting
with licensed conlraclors�o construct the projecf(Sec- N'Ait � * � .
tion 7044,8usiness ond Professions Code). - A�DRE55 //�
CONSTRUCiION LENDING AGENCY Cliv � s� T .NO. �J �
I hereby offirm ihat there is a cons�ruc�ion lending agency for ,
ihe performonte of Ihe work for whith this permil is issued � CONTRAC70R �{� " " � � �"� ' �
(Sec.3097.Civ.C.). . .-. . . -- .
� � ADDRESS / y - . . . .. � � . . ._ . ' . . . .
Lender's Name '7
. . [IN . �. _. TEL.N0.�.1 � � _ .. _.. __ . . . ... . _
Lender's Address
STATE LIC.
I certify ihat 1 have read ihis applicotion ond srate that tha �ICENSENO. � - CLA55 � � �� �� � -��� � � � � � ��� � �� �
obove information is correct.I agree�o tomply with oll Co�nty
ordinonces and Stole laws relating 10 bu�lding construUion, , .
ond hereby authorize representotives of this County to en�er . - � � ����� ��
upon Ihe obove-menlioned property for inspeclion p�rpos s. - SEE REVERSE FOR EXPLANATORY LANGUAGE
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