HomeMy WebLinkAbout1164A (5) WORKERS'COMPENSATION DECIARATION APPLICA 1 ION FOR PERMIT �
I hereby affkm that I have a certificate of consem ro�se�f . .
Insure,ora terfiiitole of Workers'Compensation i�s��a��e, ,bA364c � .�� HEATING --VENTILATING - AIR CONDITIONING
or o certified copy thereof�Sec.3800,lvb.C.) � � ��:B�e(eN.lOiB�) � � � � � - - - � �
f..6tA'�a
P❑olicy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certif�e c�op��reby furn�shed.`a e un 4E324 JOBn 1111 PHn 4
� CeniXed copy is filed wl�h iha counry buiid�ng�ospea ' FOR APPLICANT TO FILL IN sunoiN�
tion deportmenl. � ADDRE55 20764 East tdill Lane
(PRINT OR TYPE ONLY) .
Date Z�3-$7 Applicant LOfAIITY � .
NO. TYFE OF APPLIANCE OR EQUiPMENT . FEE
CERTIFICATE OF EXEMPTION OM WORKERS'. - NEaREST �
COMPENSATION INSURANCE . . Ca055 ST.
,(Thls saction nood not be tompleted if Ihe work Invoived by ABSORPiION UNI7,BTU 0151RiCE NO. PROCESSED BY
tha permtl Is(or one hundred dollan(5100)or lese.) q
I cerlify Ihat in Ihe performance of the work for which lhis A�R HANDLING UNIT,CFM 1-� �I rn �`�
- permil is issued,I sholl no1 employ any person in any monner gOtLER,BTU
so os to become wbject to�he Workers'Compensation laws. avvaovnis D/.LE � WSPECtOR'S SIGNATURE _-
. Da�e /+pplitant � COMPRESSOR,BTU ROUGH ��, �./
NOTICE TO APPLICANT: If, after.moking this Cer�ifica�e Of ' VENTIUl710N SVSTEM FINAL ��a,A�
� Exemplion, you should become subject to the Workeri .
Compensolion provislons of the Labor Code,you must forth- EVAPORATIVE COOLER � . � VALIDATION �
with wmply wiih such provisions or this permil shall 6e .
' �deemed revoked. � FURNACE: FAU�_GRAVITY - -
" LICENSED CONTRACTORS DECLARATION � ROOR BTU �
I hereby aifirm�hat 1 am licensed under provisions of Chapler 9 HEATeR: SUSPENDED uNiT_
'(�ommencing with$ection 7000)of Division 3 of�he 8usiness �'�'A«
and Professions Code,and my license is in iull force ond effect.� . . y
. . �� 7 � . � 0�
. License Number A,�.eQ�w� tic.Class.���8 ' -- � _ �� , V
IrvineWest a
Contmctor Dare �-23-87 ' O
r-
o � �
�am ezemp�under Sec. a
Plan check fee
� B.BP.C.for ihis reason' � N
PERMIT ISSUING FEE S � ?
Do1e:
Signatu�e TOTAL FEE 00 �� � �x Q r'�
� OWNER-BUILOER DECLARATION - MN CHECK AaPLICANT . fj e • • a e 8
1 hereby offirm tho�I am exemp�from thc Conrrador's license D � �
taw for the fallowing reason(Settion 7031.5,B�siness and NMAE � • •(��'O�
Vrofessfons Code): � ' � �
❑ I, as owne�of the property, or my employees wiih AODRE55 • � ^�1^�Q T
wages as their sole compensolion,will do the work and CITY TEI.NO. � U n v i-i?7
the structure is nat intended or otfered for sole(Sec�ion ,
7044,Business ond Professions Code). .
owNFR
❑ I,as owner of the properly,om exclusively controcting �
with licensed coNraUors lo construcr the projed(Sec• ^�A�� - � - �
tion 7044,Business ond Professions Code). � Ao�RESS
r r
CONSTRUCTION LENDING AGENCY - � - � - - -� �
---
I he�eby affirm ihal there is a consrrot�ion lending agency for �IT Netuoo=t Bedch 92660��'NQ714) F333-3600 �
the perfo�monce of the work for which this permil is issued- �� CONTRACTOR �� �' "��� ��� " � � - � ,
(Sec.3097.Ci�.C.�. . • . • .._. . _. ; _. .
� ADDRE55 _ .. .. . _. . . � .: . .,.. :. . _... . _ .
Lender's Name
� . GTY. TEL NO. , . . . . . . ..
Lender's Address - '
STATE LIC. ' '
I certify thor I hava read fhis application ond slale thal the- LICENSE NO. -� 468609 �CLA55 �C-20 - - -- -- - � �- � � � - - �� -
a6ove infoima�ion is torrect.I agree to comply with oll County . � .
ordinonces ond State lows relating ro building construction, ' '
and hereby authorize represen�a�ives of this Couniy io enter � � ��� � � � �� �� � - � - -
�on the obove-m niio�ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUACE . _
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