HomeMy WebLinkAbout1155A WORKERS'COMPENSATIONDECLARATION � � APPLICATION FOR �LRMIT �
I hereby ofihm�hat I hove a certifico�e of consem lo self
insvra,o�a cerrificate of Workers'Compensation�nsurance, �bA364c HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,lab.�C.J "� - �
CE-818(REV.10/81) . . . . . . . �����
Poltcy Na.,_ypQ],5],G_Company Stata FnnA �
� Ce�tified mpy is hereby furnished. TR-ur 44824 �OUNTY OF LOS ANGELES JOBn 1111 gUILDING AND SAFETY?Fi°n 4
� Ceri�ed copy is filed wiih the county building insper FOR APPUCANT TO Flll IN ewmiNG
tion deportment. ADDRESS 20712 Sast Mill Lane
. (PRINT OR TYPE ONLY)
Daie�— �r�APPlicant IOCALITY
NO. NPE OF APPLIAN�E OR EOUIPMENT FEE 1diS1
CERTIFICATE OF EXEMPTION F WORKERS� NEAREST
COMPENSATION INSURANCE � - Ce055 ST. �
(Thft set}lan nood no}6a complaf�d IF fhv work(nvolvad by� ABSORPTION UNIT,BTU DRIRi�I NO. vROCE55ED BV
fhe permil i�for one hundred dollars(SIDO)or lass,) . � /�� ��
AIR HANDLING UNIT,CFM �
I certify thot in the performonca of the work for which this l���
— permir is issoed,I sholl noi emptoy any pe�son in ony manner gOILER,BTU --
so as to become sv6jecl to tha Workers'Compensalidn Laws. avvaovais DAIE INSPECTOR'S S�GNATIIeE
Date /+ppliwnt � COMPRESSOR,BTU ROUGH '� �
NOTICE TO APPIICANT: If, afler making this Cenificate of VENTIwTION SYSTEM FINAL 2��
Ezempfion, you should become subject 10 Ihe Workeri
Compensation provisions of ihe labor Code,yau must fonh- Evnw�RATNE CCC:ER ' VALIDATION
with comply with such provisions or �his permit sholl be
deemed revoked. � - - � FURNACE: FAU-3E—GRAVITY
LICENSED CONTRACTORS DECIARATION ROOR � eTU _
I hereby otiirm that I am licensed under provisions of Chapter 9� SuSVENDFD uNii_ � .
� '(commencing with Section 7000)of Division 3 0(the Business HEATER: WA��
and Professions Code,and my titense is in full force and effect. � � �'
G.
�
License Number �68�9 Lic.Class._.� �g ' " , u
�1155k �
Contracfor TrvirfeNest Daie � 7-23--87 . . . .. - . . . -/�� �•� .8 V
❑. I am eaempt under Sec. - � ,. . _ • � �� w
8.8P.C.for this reason Plan theck fee � � • rJ��� Z
PERMIT ISSUING FEE S -
Oafe: • e e j j,'J.(',x_
Signawre TOTAL FEE ' -
. - OWNER�BUILDER DECLARATION PLAN CHECK APRICANT O�O J—�7
I hereby oilirm thot I am eKempt from the•Contrador's License- . �
Law for tha follawing reason(Sedion 7031.5,Business and NAME . . .
Profesvons Code): . ' � . �_ -
❑ I, as owner�of the pinperty, or my employees with ADDRESS - .
wages as their sole compensation,will do the wo�k and
fhe structure is no�INended or offered for sale(Section � CiTY TEL.NO.�
7044,8usiness and Professions Code). . ��
OWNER
� ❑ I,os owner of the property,am exclusively coniractin9 � _ '
wilh licensed mntradors to construct the project(Sec- ^^Ait� � -
tion 7044,Business and Professions CodeJ. ADDRESS
CONSTRUCTION LENDING AGENCY � - - � . � � .
I hereby oifirm thot there is o constrociion lending agency for ��TM Net ort Beach 92660TE�.N�714) 833-3600 •
�he performonce of�he wo�k for which�his permit is issued� �pMRACiOR ' � � � ►
(Sec.3097,C�v.C.)• -� -� . . , . .. .. . .
- . ADDRESS- . _. _ . . . _'..._.. . .._._. . ..' -. �. ..-._.�_... .. _ .
lender's Name
� . .. CITY TEL NO. — HO . _' .' .' ' . ... . .. . . . . .
Lender's Address
I tertify thot I hove read this applicotion ond sfate ihat the - �j�NSE NO. �j C ASS C-2� -- � �- � . .. . - . . .
obove iniormo�ion is mrred.I ogree lo mmply with pll CouNy .
ordinances and Stote laws relming to buitding tonstruction, � . _ _ . : , .
� ond hereby ao�horize represematives of this CooMy to enter � � � - �� � � � "
up the abo�e-mentioned property for inspection parposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .. _ . �
Sg uie o(Appt�cant or Agent Da�e . .� .. . . .. .. . .-" ' - . . . - . .. .�./ .
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