HomeMy WebLinkAbout0878A (4) WORKERS'COMPENSATION DECtARATION APP��CATION rOR PER�y��T 'I
I hereby nffi+m that I have a certificate of consenf to self -
i�sure,or a certifimte of Worked Compensation Insurance, ���� HEATING - VENTILATING - AIR CONDITiONING ts
or a certified topy tbereof(Sec 3800,Lab.C.) � _ �
- CE-818(REV.10/81) � �
P❑alicy No. Company -
Certi#ied copy rs here6y fumished. COUNTY OF LOS ANGElES BUILDING AND SAFETY
� Cerfifietl copy is filed w�th The County building inspec- FOR APPLICANT TO FILL IN 8������ �'Z �
tion deportment � (PRIN7 pR TYPE pNLV) A6DRE55
Dnte _ Applicant - . . ioc4uTY �
� NO. TYVE OF APPLIANCE OR E4UIPMENT � FEE ,
- CERTIFICAtE OF FJ(EMPTION FROM WORKERS' N�s+r�ST
� � COMPENSATION INSURANCE � CROSSST.
(This aacllon�d not kw eompbfad if Fhp work Imolv�d by Ag50RP�lON UNR,BTU DISTRICF NO_ PROCESSEO BY
tho permtt.is for one hundrad doltan(Si�O)or la�s.} T
1�certify thot in the performonce of the work for which ihis �11R HANDLiNG IJNIT,CFM f V
permit is issued,I shali not employ ony person in any manner gp��ER,BTU
so as to becoma subject to the Viork 'Compensation laws. navaovnis onre iNsrettoa�s s�cru.ruue
DpfB "i/�2 S+ 4 . GOMGRESSOR,B7U ROUGFF ��--r
li
NOTICE TO APPLICANT.P�,�after aking this Certifi e_of VEMIIAT�ONSYSTEM FlNAL ,(�'+2,�(/ �q___�
Exempfion, you shoul b e subject to the Workers'
- Compenwtion provisions o the Labor Code,you must farih- EVAPORAFIYE COOLER - VALIDATION
with tomply with soch provisions or �bis parmit shal4 be ,
deemedrevoked. FURNACE: fAU_GRAYITY
LICENS€D CpNTRAC{ORS I?€CLARAFION-� FLOQR eiU
- I hereby offirm that I om iicensed vrder p�ovis�ons nf Chapter 9 ��: SUS�N�E6 UNIT_
'(commencing with SeBion?000)of pivision 3 of the Business - WALL
and Vrofessions tode,and my Itcense is in fult forca and effecf.- -" _ /- . y
Ia-�..�� S U fN
License Number --��y���1'tc.Uoss � �� �, - � , � ► V
p,,,�,�`- �
CoMmttpr �`���yr Date /./?/ . �
N
� Y am exempt undec Sec.- - --- ���- - .. �Ci�7��A W
Plan check fee N
e.&P.C.for th�s reason PERM17 ISSUING FEE S Q $F a � � ! �� 'Z
._Date: TOTAL fEE !lj] � a ��<.O C)
Sigrwtute
PtAN CHECK APPLICANT � • • �G L-i.1 i}_
I hereb off� ot I-am exemp�from the Contratlor's license� .
Law for e fo8owing reason(Sedion 7031.5,Businass and NMhE � � d�,� .�,-�g
Profeuions Code): � � � - .
❑ 1, as owne�of the properry, or my employees with �DRE55
wages as their wle campensation,wiil do fhe work and ��n TEl.NO. —
ihe siruciure is not iMended or offered 4or sale(Section
70d4,Business and Professions Code). - - � -
OWNER
C�, j,os owner of ihe property,om exdusively conirading � , '
with licensed conlractors to construd the project(Seo- N'p'�� � �
tion7044,Business and PrafessionsCodeJ. .4oDRE55 ,v l+'
CONST&UQION IENDWG AGENCY � - - - �y---'- a 7EL NO. ��y�`/ 3�G
I here6y affirm that ihere is a construction lending agency for �
tbe performance of the work for which this permit is iasued- CONiRACTOR
(Set.309T,Civ.C.). . � �/r - �� �
- - - AWR¢SS �j/ �/(i .. _ ..___. '.-.� . . �
Lendar`s Name
. CITV TEL NO. . _ �
lender's Address � �,!
1 certify that!have read ihis apptication and state that the- LiCENSe t�10. y�'�7� � CtASS Q �
above infwmation is twrect.1 agree to comply with all County � .
ordinances and State laws relating 10 building construction, �
and hereby aulhorize represenfatives ofi 1his�County to emer - !,
upo� e obove•menrioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�: ture of�Applicani or Agent � Da�� . . . .. _ .�.. �
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