HomeMy WebLinkAbout1276A WORKERS'COMPENSA710NDECLARATION APPLICATION FOR PERMIT �
I hereby af(irm Ihat I hova a certificole of consenl 10 self
insure,or a certificate oi Warkeri Co s wf�A3�� �HEATING - VENTILATING - AIR CONDITIONING
• or a cer�ified co y thereof Sec.3800. �v CE-B18(REV.10/81� - � � �
��Y /// mp��Y COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy fz hereby furnished.
� Certified copy is filed with the coumy 6uiiding inspec- FOR APPLICANT TO FILL IN su�to�NG �Cr S' •
fion de 1m 1. � (PRINT OR TYPE ONLY) ADORE55 J �
� �
Data / � APPIicoM � LOGALITY vl,��-�
NO. NPE OF APPLIANCE OR EOUIPMENT � - � FEE �v
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � " • /J
COMPENSATION INSURANCE . Cu05557. � C(�/.�['T/L 1
(This sxlion naad no1 6e tomplafad I(Ihe work Involvod by ABSORP�ION UNIT,BTU DISiRi�I NO. CRp�ESSfD BY
Ihe permlt If(or ono hundred dollars(5100)or les�.) qIR HANDLING UNIT,CFM Q
I�certify ihat in the per(ormonce of Ihe work for which ihis 1 m�`d{��
permil is issued,I shall_not employ any person in ony manner -
— so as to become subjetl lo Ihe Workers'Compensotion Laws. BOILER,BTU novaovats DAiE INSofCiOR'S SIGNATURF
� Dofe Applitont COMPRESSOR,BTU v� OUGH �O v
NOTICE TO APPLICANT: If, after making this Certifica�e af VEMRATiON SYSTEM FINAL ���'� ��
Exemp�ion, you should became s�6jecf �o �he Workeri
Compensolion pravisions of Ihe Lobor Code,you musf forth- EVAPORATIVE COOLER VALIDATION
� with comply wilh such provisions-or ihis permit ihall be
fJeemed fevoked.� � � � � � FURNACE: FAU GRA ITV .
LICENSED CONTRACTORS DECIARATION Fi00R BTU
� I hereby ofiirm Iho1 I am Iicenzed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
'(commencing wilh Section 7D00�of Division 3 of the Business ' WA«
and Prafessions Code,and my license is in full force and ei(ect. - - q� . a
`/+ 7-� L
License Number�Lic.Class`—' `�' . _ O
�127,6A v
Contractor ote � J �" - , ��• : • • •8 O
� v
I am e:empt under Sec. I • •5�2 5 a
Plan check fee
e.ar.C.fo�rh�s reosan pERMiT ISSUING FEE S O ' ' '�a�5� Z
Dale:
Signafure
TOTAL FEE � 0&3 1 —B 8
� � OWNER-BUIIDER DECLARATION � anN CHECK nvalKnM
I here6y aifirm Ihat I am exempt(rom the CoNrac�or's license � �
Low for the following reoson(Settion 7031.5,Buziness and NAME � .
Professions Code): ' -
❑ I, as owner of rhe property, or my employees wilh ADDRE55 -
oges as Iheir sole mmpensolion,will do the work ond GITY � TEL.NO.
�he s�rvcture is not imended or offered for sale(Section
7044,Business ond Profes:ions Code�. �
OWNER
❑ I,os owner of the property,am exdusively coNracting .
with licensed canlrado�s to construcl the projed(Sec- ��� / � -
� tion 7044,Busines:ond Professions Cade). � ADDRE55 ( I�Gt,�
CONSTRUCTION LENDING AGENCY � l' .
CI7V /' � G� � TEL.NO. l� �
I hereby efiirm thot there is a constr�dion lending agency for «
the performance of the work for whith this permit is issued COMRACTOR � ' - � , �
(Sec.3097,Civ.C.). � . ....._ . . ...._ .:__ ... ... _
- � � ADDRE55 6� r. . . . .. - � .. . . _. _
Lender's Name
' CITY � TEL NO._��(' � . . . _. . ...
lender's Address
I cerliF Ihat I have reod this applicotion and state thot the StATE ` `�)>(� l�C, /'_�l ,
UCENSE NO.� "[�",S�L QA55 (� �--e�
above i formmion is correct.I agree to comply with all Counry _ .
ordinances and Stote laws relating fo building consiruction, � � -
and hereby authorize representalives of this Counry to en�er � � � � � -� -- " " '"�� �
opo he above-menfioned property ior inspeciion pwposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
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