HomeMy WebLinkAbout0884A (4) � •WORKERS'COMPENSATION�ECLARATION APP�,'CAT�ON FOR PERMIT �
I here6y affkm that I have a cernficote of consent fo self
insu�e,or a certifitate ot Workers'Compensation Insurance, �6n�aac HEATING -"VENTILATING - AIR CONDITIONING
, or a ce«ified copy thereof(Sec.3800,La6.C.J � -�.ete(REV.10/et) � - �� � -� - ���� - -� �
P❑ol�ty No. Company COUNTY OF LOS ANGELES. BUILDING AND SAFEiY �
�Certified copy is here6y furnished.
� Cerufled copy is filed wfth the coumy building inspec- FOR APPLICANT TO FILL IN Bu�ID�NG a.��fl � ��
fion deporfinent. . (PRIM OR TYPE ONIY) ADDRE55
Date Applicant� .. �OCnuir � e �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �
- COMPENSATION�NSURANCE � � . CRO55 57.
.(Th(s sacllon naod no}6e tomplafad if fho work Involvod by aB50RDT10N UNIT,BTU DiS�RiCi NO. � PROCESSED BV
Ihe parmif fs for one hundred dollars(S�DO)or less.) AIR HANDIING UNIT,CFM
I certify fhol in the performance of the work for which this 1 O �9
permit is issued,I shall not employ any person in any manner /�j�
. so os to become wbject to rhe Work i omp fISa�IDl1�C S B�ILER,9TU �O �) APPROVAlS pATE . INSVECTOR'SSIGNANRE
�Da�e pplitant COMPRESSOR,BTU ROUGH
NOTI E TO APPLICANi: If, atter makin this Cerlifica�e oi VENTiIATiON SYSTEM FINA�
Ezemption, you shouid betome subject to the Worken'_
Compensalion provisions of Ihe Labor Code,you must forth• . Evt 70BqiivE COOLER � � VALIDATION
wi�h comply wifh such provisions or this permit sholl be .
deemed revoked. � - iURNACE: .FAU_GRAVIN �
�LIGENSED CONTRACTORS OECIARATION FLOOR � BTV .
� I hereby oHirm that I am licensed under provisions af Chapter 9 HEATER: SUSPENDED UNIT_ �
'(commencing with Seclion 7000)o(Division 3 of the Business WA« �
ond Professions Code,and my licensa is in full force ond effed. � - � - �"
a
O
License Number Lic Class . � -- �- � - , � U
a
CoMrotbr Dale . .. . - . �
❑ � .
1 am e.empt under Sec. w
Plan check fee � N
B.SP.C.for�his reasan - pERMIT ISSUING FEE S �� SC� z�S fl 4 R ?
Date:
S�gnature TOTAL FEE ` � #• • . ..�$
OWNER-BURDER DECLARATION � PInN CHECx nP7uCAruT � �,/'� �I.• •3 Q 5 0 �
I hereby affirm that I am ezempt from the Contractor's license-- �J . �
Law(or ihe following reason(Seclion 7031.5, Business and NAME � f •�� •J�.S(�_
Professions Code): ' U
I,as owner of fhe property, or my�employees with /+DDRESS 3 � � . 0!z 2-1 —8 5
woges as iheir sole compensaiion,will do�he work and �
ihe srructure is not imended or offered for sole(Section CITY Til•N .�J "3 1 \
7044,Business and Professions Code).- . . �� �
OWNER S � '
❑ I,os owner of ihe property,am exclusively contracfing � J �
wiih licensed controtlor5�o tons�rod the projec�(Sec• �OL � . �- � - -- -
�ion 7044,Business and Profe55ions Code). A�DRESS �
CONSTRUCTION LENDING AGENCY � CITY - � � TFL NO. " �' �
I hereby aFFirm thaf the�e is a tonstroction lending ogency for , .
Ihe performance of Ihe work for which lhis permi is issued CONTRACTOR- - � � �� -- -
(Sec.3097.Civ. . � .. . .- . . . ., . .. .. .
� ADDRE55 � � - � --- -- �� . . � � �'
lender's Nome �
qTY . .. TEL NO. .
Lender's Address Gy�� �� �� �� � �- - �
$7ATE- � IIC. .
I cerlify�hot I have read this applimtion and s�o�e thot�he _ LICENSE NO. ��� � -CLASS ��� � ��� .. . .
above inFormation is mrrect.I agree ro tomply wi�h oll CouNy - . � . � ��
ordinances and Stale laws relating to building tons�ruclion, � . .
he�eby authorize representatives of fhis Coonty�o en�er � � � � � � � - --- " � �-
p t e a'ove-menN�d pro erry foi'nspection p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _
/C�Signaiure of Applf�o��or Agen� � Da+e � ' . . . . .. . _ . . . . . . . . �
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