HomeMy WebLinkAbout1159A (5) WORKERS'COMPENSATION DECLARqTION �
I hereby oifKm�hat I have a certificate of consenl to self APPLICATION FOR PERMIT
insure,or a certiticate of Workers'Compensotion Insvrance, ��3�� HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) " -
� CE-BIB�REV.10/81) . - . . �t���
��Y N� C�mP��Y COUNTY OF LOS ANGELES BUILDING AND SAFETY
CertiR c�bpy is 1'�ereby furnished.`a e un R# 44824 JOB$ 1111 PH# 4
� CerfiRed copy is filed with the county buiid�ng inspeo- FOR APPLICANT TO FILL IN BUILDING
tian deparlmenl. (PRINT OR TYPE ONLY) � AD�RE55
Dole 7-��-$� APPlicant � LOCAtITV
NO. TYPE OF APPIIANCE OR EOUIFMENT � FEE
CERTIFICATE OF EXEMPTION F-� � NEAREST
COMPENSATION INSURANCE � CROSS ST. �
, (ihis sedfan need nof 6e mmplotod if tha work Involvad 6y . ABSOavTiON UNiT,BTU OISIRtCI NO. GROCESSFD BY
}ha parmi}is(or one hundred dollon(5100)or lasf.) AIR HANDLING UNIT,CFM � / i� �/
, I certify that in Ihe performante of ihe work for which ihis
permit is issued,I shall not empioy ony person in ony manner gOiLER,BTU
so as to become subject to ihe Workers'Compensotion Lows. nvvxovais DATE MSPECTOR'S SIGNATURE .
Da�e ' opplicant � � t COMPRESSOR,BTU ROUGH . '
NOiICE.TO APPLICANT: If, aNer moking this Certificote of � vENi�LATiON SYSTEM F�NAL ,/`�/ �
Exemption, you should become subjec� �o the Workers'
Compensa�ion provisions'of the La6or Code,you m�st forth• EyqppRATNE COOIER VALIDATION.
wi�h tomply wilh such provisions or this permit sholl be
deemed fevoked. FURNACE: FAU GRAVITY
� � LICENSED CONTRACTORS DECLARATION F�OOR B��
�I hereby aifirm tha�I om licensed under provisions of Chap�er 9 � SUSPENDEO uNiT_ .
HEATER: WA��
-�(commencing with Section 7000)of Divis�on 3 of the Business
and P�ofessions Code,and my license is in full force and effed. - G � � � � �� � � �'
a
license Number Q666B9 ���•Class e_�e - - , V
Conrraaor Irvine47est Da�e 7-23-fl7 �1 1 5 9 A �
v
❑ I am exempt�nder Sec. � � � � � � �
Plan check fee r� � a
8.8P.C.for rhis reason' . . . pERMIT ISSUING PEE$ - �'' "4��� z
Da�e: •
Signa�u�e TOTAL FEE • � •ll R Q Q=
� " OWNER-BUILDER DECLARATION PLAN CHECK A7PLICANT � ' O�O J��7
I hereby offirm fhat I am exempt from the Conrractor's license �
Law for the foilowing reoson(Section 7031.5, Bus�ness ond NnME � '
Professions Code�: � � .
❑ 1, as owner af the property, or my employees with ADDRESS -
wages as their sote compensation,wiil do the work and �
Ihe structure is not intended or ofiered for sale(Section CITY . TEL�!O.
7044,6usiness and V�o(essions Code). . , . --- . -
OWNER
. ❑ I,as owner of 1he properly,am eKclusively conlrocling �
wilh litensed contractors to conslruct ihe pro�ec�(Sec- ���� . �
tion 7044,Business and Professions Code). AD�RESS
GONSTRUCTION LENDING AGENCY � ��TM N2b7 ort 9each. 92660'E�."4.714) 833-3600
I hereby affirm ihat�here is a tonsfr�dion lending ogency for , .
the perto�mance of the work far which this permit is issved - CONiitnQOR � �- � �
(Sec.3097,Civ.C.). • ' .. .. _ _. . ....... _ . _ . . _
� � ADDRESS � .- _ . . � .._ �
Lender's Name � - - -
_.. CITY . . TEL.NO.
Lender's Address - � -� � -��- �
I certiF Ihat I hove read Ihis a litation and sfaie thal 1he_. STA7E ~ � LIC.
Y PP IICENSE NO. - .CLA55. .C-2�.. ... . . . .. ..
above iniormation is mrreU.I dgree to comply with oll Counfy . � � .
ordinantes and Siate laws relating to building conslrucrion, - , � ,
ond hereby authorize represeMolives of this County��o eNer - � - - - � -�� � - � ' � ' - �� �� �� ' - �� - - ,
yqon the above-menuoned property for inspetlion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
/ � �3 87
natura of Applimnt or Agent Do�e . . . .. .. . - .. . . . � . . . .. .
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