HomeMy WebLinkAbout1152A WORKERS'COMPENSATION DECLARATION qPP11CATi0l�! FOR PERMIT �
1 he�eby affirm that I ha�e a certificafe of consent to self
insure,ar a certificate of Workers'Compensation Insurance, ���� HEATING - VENTIlATING - AIB CONDITIONING
or a certified copy rhereof(Sec.3800,Lab.C.) �cE-ela(REv.loie�)
PolicyNo. Company ate Fund � - - �.J/'��g
❑ Certifi3�Qopg�ere6y fiurn�shg� TR�` 44824 �OUNTY OF LOS ANGELES JOB# 111I BUILDING AND SAFETY p�# 4
�/ Cert�Led copy is filed wi�h the coumy building in� FOR APPLI[ANT T�FILL IN BUIL�ING
'•[ fion department (pRiNi Ou irre ON�v� ADDRE55 20701 East Mill Lnae
Dote-�-��-��� Applimnf - LOCALITv
NO. TVPE OF APPLIANCE OR EqUIPMENT FEE
CERTIFICATE OF E%EMP710N OM WORKERS' , , NEAREST �
COMPENSATION IN URANCE CRO55 5T. �
(This sxfion noad nol ba completad if tho work�nvolvod by Ag�RPTiON UNIT,BTU DISTFICi NO PRp�E55ED BY
Tha parmiY i�for ona hundred dolfon(5100)or lacs.) qIR HANDLING t1NlT,CFM a-- �� �.��
1 certify ihat in ihe performance of ihe work for which�his
permif is iss�ed,�sha�l not employ any person in any manner BOIIER,BTU
so as 10 become sv6ject to the Warkers'Compensation LOWS. APVROVALS DATE INSPECiOR'S SIGNAiURE
Dole npplicant COMPRESSOR,BTU ROUGH . �
NOTICE TO APPLICANT: If, afler making this Certificate of vervnlarloN SYSiEM FINAL (�[
Exemption, you shou�d become subjec� to the Workers'
Compenwtion provisions of the labor Code,you musE forth- EVAPORATIVE COOIfR VALIDATION
with tomply with such pravisions or this permit shall be
deemed revoked. FURNACE: FAU�_GRAVITY
LICENSED CONTRAC7pR5 DECLARATION ftOOa BiU
I here6y affi�m ihat I vm licensed under provisions of Chapter 9 HEATFR: SU5PENDED UNIT_
-(commencing with Section 7000)of Division 3 of the Business - WA��
and Profassions Code,ond my licenae is in full�forte arid effed. � Y
� B.
License Number ��g�e4 ��c Class ��g � O
V
CoNmcl�r Irvine4Jest oa�e 7-23-87 �
Q
❑ r
1 am eaempr under Sec. W
Plan check fee
B.BP.C.for this reoson � vi
Date:
PEitMiT ISSUING FEE S z
Signature TOTAL FEE �
0
OWNER-BUILDER DECLARATION FLAN CHECK APPLIGqNT �:. .::�
1 hereby affirm ihal I am exempl from the Conttacror's License
Law for the following reason(Section 7031.5,B�siness and Nnnne , �I � •C..�.'i��
Professions Code):, ,
,,�.._
❑ 1, as owner of ihe p�operty, or my employees with �DRE55 • '' E 4 f: : u
wages as iheir sole compensation,will do the work and -
the structure is not intended or offered for sale(Sedion CITY 1EL.NO. U:�.U J-�S 1
7044,Business and Professions CodeJ. ,
OWNER
❑ 1,os owner nf�he�properry,am exdusively contracting
with licensed contmctors fo construcf the project�Seo ���
tion 7044,Business and Professions Code). ADDRE55 �
CONSTRUCTION LENDING AGENCY ��TY Nec ort Beach 92660TE�."P71�4) 833-3600
1 hereby affirm fhat fhere is a consirucfion lendin9 agency for �
the performonce of the work for which fhis permit is issued CDNTRACfOR �
(Sec.3097,Civ.C.).
ADDRE55 - � �
lendei s Name �
' CtTY TEL.NO. �
lender's Address
STATE LIC.
1 certify that I have reod this application and state that the L�(�NSE NO. �Lq`„$ C-
o6ove information is corred.I agree lo comply with all County . .
ordinonces and State taws relating l0 6uilding consiruction, -
and here6y au�horize representatives of this Coun�y�o enter �
on the above-m�tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
, 7-2�3-.37
aiure of Appliconr or Agent �a1e
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