HomeMy WebLinkAbout1156A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affrm thal I have o certifim�e of consent�o self .
insure,or a certifica�e of Workers'Compensation Insurance, �aA36ac HEATING - VENTILATING - AIR CONDITIONING
or a certifled copy ihereof(Sea 3800,Loh.C.) � CE-B�e(REV.�Oiei)
Polity No. 102151G Campany StdtO Fund � Lvt#�oZ -
❑ Certitied copy is he�eby furnished. TR'� 44324 �OUNTY OF LOS ANGELES JOB',� l.11l BUILDING AND SAFETY PH� �
a Cert�ed copy�s filed with�he county building inspec- FOR APPLICANT TO FILL IN BU��o�NG
tlon depo�lmenl. , � (PRINT OR TYPE ONLY) A�DRE55 ZQ']],$ East t4i11 Lane
Date 7-23-87 Applicant – � .–�''� LOCAUTY
NO. TYPE pF APPLIANCE OR EOUIFMENT FEE
CERTIFICAiE OF EXEMPTION F M WORKERS' NEAaEST �
' COMPENSATION INSURANCE CROSS ST.
(Th(f se[}ion nead not 6e complotad iI flle woflt Invoived Ily . ABSORPTION UNIT,BN DISiRICE NO. vRp�E55ED BY �
Iha parmi)Is�o�ono h�ndred dollers(5100)or less.) � AIR HANDIING UNIT,CFM � � � � + - �—
I cerlify Ihol in ihe performance of Ihe work for which this �/(/ �
permil is issued,I sholl not employ any person In any manner .
so as 10 become subjecl to Ihe Workeri Compensation Laws. bOiIER,BTU pPPRQVP.lS DATE INSPECTOR'$$IGN/�TURE
�pte APPli�ant - CON�PRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If,.ofter making this CertiFicote of � VENTILATION SVSTEM FINAL
Exemption, you should become sobjed to �he Wo�kers'. .
Compensa�ion pravisicn:ot the Lobor Codr.,you must(orth- EVaaOBATIVE COOtER VALIDATION
with camply wilh such provislons or Ihis permit sholl be
deemed revoked. � FURNACE: FAU�—GRAVITY ,
IICENSED CONTRACTORS DECLARATION � FLOOR BTU .
� I hereby affirm thol I am licensed�under provisions of Chapter9 SUSPENDED UNIT_ �
'{commencing with Section 7000)of Division 3 of�he Business HEATER: wA�� .
ond Professions Code,and my license is in full force and effed.-� �_ � - ' �'
� �
license Number a68.609 Lit.Clau �_20 - ��`$'�'e�� � � , =1 1 a 6 A V
IrvineClest 7-23-87 #• • • •8 O
CoNrocfor pofe �
- ❑ �1 am exempt under Sec. � ..., _ . ._ , � • °4�Q� a
Plan check fee y
8.8P.C.for ihis reason� „ PERMIT ISSUING FEE S� � • •�•1�H G O i ?
Dote:
5gnmure TOTAL FEE_.... Q 0 0�'��j-t,j'J
. - OWNER-BUIIDER DECLARATION PIAN�HECK A7PLICP.NT � .
I hereby a(firm that I am ezempt(rom the Contracror's License . � -
low for 1he following reason(Section 7031.5,B�siness and NAME
Professions Code): •
❑ 1, as owner of the proper�y, or my employees with ADDRE55. .
� wagas as their sole compensalion,will do the work and � - '
� the siructure is nof intended or of(ered for sale(Setlion CITY TEt.NO.
7044,Bosiness ond Professions CodeJ. , , ' - .
OWNER
❑ I,as owner of�he properry,om e.clusively con�mc�ing � _ , - �
with lirensed coNracbrs ro construct the projed(Sec- ��� - '-'�-��
tion 7044,Business and Pro(essions Code). � /DDRE55 �
CONSTRUCTION LENDING AGENCY - - � - – ��
I hereby affirm thal lhere is a conttruction lending agency for � �'rvNBW ort Beach 92660 TE�'�l°!14) 833-3600 �
the performance of the work(or whicfi this permit is issued GONTRAC'fOR � "�- � � ' � � � � �
�Sec.3097�Civ.C.). . � . . .:. ---. _. _. ... _.
. � AD�RESS. � � . . .. . ....... . '�, , :: . . .
Lender's Name � � - .
. _ UTY TEL.NO. ___.. ... .. .
Lender's Address � – � ' � � � � -
r
STATE LIC. �
I certify that I have reod this applimtion and siote ihal ihe LiCENSE NO. - -�ttn55 � � ..
_ .. . _. . . . ..
above informolion is correct.I ogree to comply with all Counry
ordinances ond Sta�e laws relaling fo building mnstruction, . , _
ond hereby authorize represen�atives of this Coonty�o en�er � � --�� �' -
up ihe obove-meniiqned property for inspec�ion p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
- � �-23-E37
Si rure a}Appliconf or Agenl Dale . . . . __. . ...... .. . .
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