HomeMy WebLinkAbout1165A WORKERS'COMPENSATION DECLARATION qpPLICATION FOR PERMIT � � �
I hereby a((km that I have a cerlifico�e of consent to self �
insore,or a cerfifica�e of Workers'Compensatian Insurance, j6A36aC HEATING - VENTILATING - AIR CONDITIONING
ar a certiiied topy thereof�Sec.3800,Lob.C.) , � ` .
ee-s�s�aev.�oie>> [(�t'/�3�
P❑olicy No.��Company $tat�x'nnA �
Cerrified co s hereb furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
PY' Y iRn 44824 JOB�9 1111 Pt�$ 4
� Cenij{ed copy is filed with ihe county b�ilding inspec- FOR APPLICANT TO FILL IN BunoiN� 20770 �ast hiill Lane
tion departmenf. ' (PRINT OR TYPE ONLV) ADDRE55
Dole�z��_APPlicanl - LOCALITV
NO. TYPE OF APP�IANCE OR EOUIPMEM FEE
CERTIFICATE OF EXEMPTION F M WORKERS' - NEAREST
. COMPENSATION INSU ANCE . CRO55 5T.
(Thts s�efion naad nof be complatad if Iho work Involved 6y ABSORPTION UNIT,BTU OISIR��f NO. VRp�ESSfD BV
� }he parml}Is for one hondrad dollars(SI00)of Iesf.J � AIR HANDUNG UNIT,CFM � �� 1.t/
I certify thdt in ihe performance of�he wvrk tor which this �
pe�mit is issued,I sholl nof employ any person in any manner
so as to become sobjed to the Workers'Compensolion laws. , BO�LER,e7U APPROVAlS DATE INSFEC70R'S SIGNATURE --
- Da1e - Applimnt COMPRESSOR,BTU ROUGH � t�g�
NOTICE TO APPLICANT: If, diier moking �his Cerfificaie of VENTILATiON Sv57EM FINAL � ��
Ezemptlon, you should betome subject to the Workers'
� Compensetion provisions of the Labor Code,you musl forth• EVAPORATIVE COOLER VALIDATION
- with comply with such provisions or Ihis permil-shall be
deemed revoked � FURNACE: FAU GRAVITY - � �
LICENSED CONTRACTORS DECLARATION FLOOR -�
I hereby affirm thot I om licensed under provisions of Chopler9 SUSPENDED UNIT_ ' �
'�commencing with Seclion 7000)of Divisiofi 3 of the B�sine55 HEATER: wA��
and Professions Code,ond my license is in full forre and eifed. - � �� � ' � }
� Q
License Number��ec)—Lic Closs��_ ' � '' � -- � ► � � V
C
Contmdor 7rvi nPWest Dale � 7-27-R7 - .. . . _ O
❑ _.. t-
1 om exempt under Sec. w
Plcn check fee •'1 1 !z 5 A y
a.Bv.C.for ihis reason PERMIT ISSUING PEE$ n• .�. . g Z
_..
Date:
Signoture '
TOTAL FEE f � •j���
� OWNER-BUILDER DECLARATION� tt/+N CHECK n7ruCnNT _ ' ' "�>�O O�
I hereby affirm Ihol I om ezempt from the Contractor's License D ���3-a�]
Law ior Ihe following reason(Section 7031.5, Business ond NAME �
Proiessions Code): �
❑ I, as owner of Ihe property, or my employees with ADDRESS � - �� �
� wages as their sole compensotion,will do Ihe work and . ,
the srructure is nor inrended o�offe�ed ior sale(Section �IN TEL.NO.
7044,Business ond%ofessions Code), � -
OWNER
❑ I,os owner of 1he property,om exdusively contracling MA4 � - �� -- � -
wiih licensed contractors to construcf the projetl(Sec- qDDRESS
� tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY �- � � - �� � � --�
I hereby offirm thot ihere is a cons�ruction lending ogency for ���ry wDo�t seaeh 92660��'N4�714 f 833-3600, � .
the performance of�he work for which this permit is issued � CONiRnCiOR � �- � � -- �-� ��- - --� - ----� �
(Sec.3097.Civ.C.). - .. . .. . _,
� . ADDRE55 . . ... . - . -. - . . .
Lender's Name � _
CITY.. _TEL.NO. '
Lender's Address - � � � � � � �
STATE �IC.
I certify that I have reod ihis opplicotion and stare thol the . pCENSE NO. - CLA55- - �� � - � - - . . ._ .._ . _._
a6ove information is correcl.I agree to comply with oll County
ordinantes ond State laws relaling to bailding[onsfruclion, _ �
ond hereby outhorixe represen�atives of this County to enter � � - '- � � � ��'�'� � �� -- �'-� � - - -� --- �
opan the above-mentioned prope�ty for insped�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. _
7—�3=87
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