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HomeMy WebLinkAbout0640A � � WORKERS'COMPENSATION DECLARATION � APP�ISATION FOR PERMIT � insure,�or aLcertificate of Worke srrCompensat o�n Insu�ran el� '- � a�a«rrifled coPy thereot(sec.3so4�ab.C.) �bnsoac HEATING - VENTILATING - AIR CONDITIONING �" � CE-818 lREV.IOBI) acy No. Company C O U N T Y O F L O$A N G E L E S B U I L D I N G AND SAFETY Certi fie d copy is here by furnis he d. � � Certi fie d mpy is fi le d wit h f he counfy 6ui l ding insper P O R A P P L I C A N T T O F I L L I N B U I L D I N G Z /f � tion department (PRINT OR TVPE ONLY) ADDRE55 �,,,fl �+. L��`� �' � Date Applicant LCCA�JiY �,� ��� �q�� �/ . NO. TYPE OF APPUANCE OR EQUIPMENT fEE CERTIFICATE OF EXEMPiION PROM WORKERS' . NEAREST . � COMPENSATION INSURANCE � CROSS 57. (This secfion need not 6e eompleted if fhe wark involved hy /+BSORPfiON UNiT,BTl1 cisieici No. vzoccssco ov � ihe permit is for one hundred dollars(S100)or less.) -- � � I certify that in ihe performance of the work for which ihis AIR HAN�LING 11N1T,CPM .. ...�-... � permii is issued,I shall not employ ony person in qny manner so as to become subject to the Workers'Compens tion Laws. 6oaER,eTU nPPeovnis onre iNsrecroe�s si�Nnrurze v '�/���p o fiG __,� COMPRESSOR,BTU ��j p�� �� �1 t,3� ROUGH m Daie =_+ — Applicant✓ !O�" FINAI gl"�.� "-"-� - ,� NOTICE TO APPLICANT: If, after making this Certificafe of VENTILATtON SYSTEM ;.-5�w,e� � Exemption, you should became subjecf to the Workers' � �� " � Compensation provislons of the Labor Code,you must forth- — Evnr�ORAr�ve COO�ER VALIDATI�N with comply with such provisions or this permit shail be deemed revoked. FURNACE FAU_GRAVITY LICENSED C6NTRACTORS DECLARAiION RoaR eiu � I hereby affirm thai 1 am licensed under provisions of Chapter 9 , HEATER: SUSPENDEO UNiT_ '(commencing wi�h Sedion 7000)of Division 3 of the Business WALL � and Professions Code,and my license is in full force and effecL . � �icense Number ��`����° Lic.Closs ���j � � �+ �[ ! , :`>L� f�i ii N � Contr�cior�j�r"�'��'Date �� � � ❑ I am exempt under Sec. — - �� � �Q �, � � Picn check fee B.&P.C.for ihis reason d � � c � ��`��'" ��. PERMIT ISSUiNG FEE$ �'� Ca �. � --Date: TOTAI FEf �jt� � a r ` Signature ' _ � � . OWNER-BUILDER DECLARATION PLAN CHECK APPLIC�NT — ��;)i'.�= ':��� . I hereby affirm that I am ezemp�from the Coniractor's License , Law for?he fol!owing reason(Se[tion 7031.5, 8usiness and NAME Professions Code): — . - ❑ I, as owner of ihc property, or my empinyees with Ao�Re55 . - wages as the��sole mmpensation,will do the work and CITY TEL.NO. � � the strodure is notiniended or oftered for sale(Sec�ion 7044,Business and Professinns Code). �p'��,;/� �,, - � . � OWNER � � ,� �ry� � , ❑ I,as owner of ihe property,am exdusively contrading MA L /' ^ /� � /�� . with licensed contractors to construct ihe project(Seo- qDDRP55 �y f� C=-/,'�s'ji1�'a"3 ��k9��xIY+ � tion 7044,Business and Profcssions Code). � � ' CONSTRUCTION LENDING AGENCY - Ci7Y l/,���d� �TEL.NO.�����C'.�3'� � � - � I heteby affirm that�there Is a construc�ion lendiny oyency for � . � - . ihe performance of fhe work for which ihis permil is issued CONTRACTOR ��+��p�� � (Sec.3097,Civ.C.). � ADDRESS �����!la,��`�� , �(�sa' _ . Lender's Name CITY //�����.� TEI.NO.�`�Y�� Lender's Address - � � � STATE yi \ LIC. 3 � . I ceriify ihat I have read ihis applita�ion and stote.ihaf the LICENSENO.7 Z.� � J � CLA55 ��� � � above informotion is correct.I agree to comply with all County � � � - ordinances and State laws relafing to building mnsiruUion, _ _ . . � and hereby authorize representatives of ihis County to enter . � � _po iry he above-mentio�rty fo�ns ectio1n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE * ! /.��' �,i �,.�. _����` SignaNra of Ap�limni or Agent Upre � - . � �.,., _. ,�, ; ��� � �- � � ,r. ,. , .. . .•p - . . *�+. °^�;, " ' ,d; .i�'���,,\' ., A • � � X� � � r.~� , � � . � . . ,, e .� � S . a� J= � � � � ' . �� r'- ' ` . �. .�,����' '•. �p� t � �� � F'� . 3 � � . ... . � Q6�. �} j . y� � h �'. f' ... .... .. .�� t�` .'' ' . . . ..+. �e , '`' � � 5 .. - � � � �� .. `.� � . ,.vr�'!s 6 m�'� � ' N N . . . . 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