HomeMy WebLinkAbout1269A (6) WORKERS'COMPENSATIONDECLARATION � APPLICATION fOR PERMIT �
1 hereby aiiirm thof I have o cerfificate of consent to self�
insvre,or a certificale of Workeri Compensation i�5�,o��e,. � . HEATING - VENTILATING - AIR CONDITIONING
• or a certi iedS�opy�fIhere (Sec.3800,Lab.C.)•n 76A36AC :�
P�olicyORf."����L� ompo�,����•,�� �-8181REV.10i81) . . . . .
Certified copy is hereby furnished- COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified topy is filed with ihe tounty building inspeo- FOR APPLICANT TO fILL IN BUILDING
tion de!p adm/g h-f. � (PRINT OR TYPE ONLY) ADDRESS 3 I S, ec� D/:
-4.i.�—u-U—APPlimn� lOG1LITY � .
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE Of EXEMPTION FROM WORKERS'� NEAREST - �
- COMPENSATION INSURANCE CRO55 ST. H pt LT .
(Tht��eetlon n�ad nof 6o complN�d 11}F��work Involved by- aB50RafION Urvit,9TU �IS�RI[i NO. PROCESSE�BY
}ha parmif h for one hundrod dollars(SI00)or la��.) . �
I tertify thol in Ihe pe�formonce of ihe work for which this� . � AiR HANDLING UNIT,CFM� /1
�J a tl�l e
_ permit is issued,I sholl not employ ony person in any monner gOnER,BTU
so os�o become su6jecl to the Workers'Compensation Laws. avvaovnts nre INSPECTOR'S SIGNATURE
Date epplicanf COMPRESSOR,BTU �� ROUGH (O r�p�
NOTICE TO APPUCANT: If, af�er making this Certificale of vErrtilATIONSYSTEM F�NA� �Z'�.�c�" G
E:emption, yo� sho�ld become subjeU to the Workeri
Compensotion provisions of the la6or Coda,y0V mu51 I0�1h- �/pppRATIVE COOIER VALIDATION
wiih tomply wi�h such provisions�o� this permit sholl be
deemed revoked. � � FURNACE; FAU KY -
� . LICENSED CONTRACTORS DECLARATION FIOOR BTu D
� I hereby affirm tha�I am licensed under provisions of Chapler 9 HEATER: SUSPENDED UNIt_ '
� '(commencing wi�h Section 700D)of Division 3 of the Business - wntL
and Professions Code,and my license is in fuil lorce and effecL�� "" " y
/ ( /� �.�, � S Q
License Number!a���ZL�lic Class�LkL -- �- � � � V
� �Da1e_� � �� 2��A O
Conhoctor -� '
❑ I om eKempl under Sec. . �• • • • •� V
W
Plan check fee I • •4 9.7 5 Z
8.8P.C.for ihis reoson pERMIT ISSUING FEE S C7
a . .49,75� I
Date:
' Signowre TOTAL FEE
� OWNER-BUILDER DECLARATION- aAN CHECK nvauCnNi
0831 -88
I hereby affirm�ha�I am eKempl from the Conlmdoi s License . �
Law for the following reoson(Secr�on 703I.5,Business and NAME � �
Professions CodeJ:� '
❑ I, os owne�o(Ihe property, or my employees with ADDRE55
woges as iheir sole compensation,will do the work ond
Ihe slructure Is not inrended ar oifered foi sale(Section CiTY TEL.NO. .
7044,Business and Profenions Code). . ��
OWNER
❑ I,as owner of the property,om exclusively toniraUing �i`
wiih licensed contractors lo construd fhe projeU(Sec- qooaeSS //��� �
� lion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ' CiTV �^ ��',c._ EL NO. S�rv�f
I here6y affi�m thof Ihere is a tonstroction lending agenq for �
Ihe perfarmance of Ihe work for which this permit is issued CONTRACTOR �l� -� � " ,
(Sec.3097,Civ.C.). � /' - ���
. � ADDRESS 6 l4� IJ1E . ' ,. _ . .. _ ".. .
Lender's Name
. . CIN TEL NO.I�/L� . . _ . . . � .
lender's Add�ess
I cerlif Ihat I have read this a lica�ion and state tha�the _ StniE � tiC. /—
y pp LICENSE NO. � � CLA55 C� �. �
above informotion is correct.I aqree to comply with all Co�nry
ordinances and Sta�e laws reloting�o building conshoUion,_ . _
and hereby auihorize representotives of ihis Coonty�o enter .
upo he obo e-meajioned property for inspec�ion purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
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