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
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