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HomeMy WebLinkAbout1035A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � I lhereby affNm that I have a certificate of consent to self . , insure,or a certificata of Worke�s'Compensotion Inwrante, - HEATING = VENTILATING • AIR CONDITIONING or a certified copy Ihereof(Sec.3800.Lab.C.) 76A36aC � . � -CE�-816(REV.10/81) ' - - P❑olicy No. � Company . .. .. ....... _ Certified copy is hereby fumtshed. COUNTY OF LOS ANGELES BUILDING ANU SAFETY � Certified copy is filed with the county 6uilding inspeo- FOR APPLICANT TO FILL IN su��DiNG fian depar}menf. . � (PRINT OR TYPE ONLY) � AODRE55 Q � Dote � Appiicant � � � -- . IOCAIIN - NO. TYPE OF APPLIANCE OR EQUIPMEM FEE �� ' � � � CERTtFICATE OF EXEMPTION FROM WORKERS' - ceo5e55,� �pp�,/ �/ � COMPENSATION INSURANCE "'--'���" � ��J (Thfs seetlon noed not be eomplalad tf Iha work involvad hy Ae50RPTiON UNIT,BTU pISiRICT NO. VROCESSED BY � Ihe permit b lor one hundred dollors(S100J or lea.) . AIR HANDUNG UNIT,CFM � �� � I certify that in ihe performanta of fhe work for which this . permit is issued,1 shall not employ on pe�son in any manner - gpi�ER,BTU so as to beco--�t�o the Work s' pensolion Laws. arraovnis DATE i oe•5 cr�nrvae - �te� � "^v pplimn ' ' ��1�Z%LCi COMPRESSOR,BTU ROUGH ^ 1 ' NOTICE i0 PPLICANT: If, afrer moking ihis Certificate of VEN71lATION SYSTEM . FINAL �` � Exemp�fon, you shoold become suhject to the Workers' � Compensation provisions of the Labor Code,yoo musl forlh- � EVnPOan7�vE COOtea VALIDATION with comply wilh such provisions or Ihis permif sholl be . deamed revoked. � FURNACE; FAU-GRAVITY � . � LICENSED CONTRACTORS DECLARATION FLOOe eTu � I hereby affirm tbot I am�icensed under provisions of Chopier 9 HEATER: SUSPENDED UNIT_ � -- � . '(commenting with Section 7000)of Division 3 of the Business � wAi� and Professions Code,ond m license is in full force and effect. . - � _ Y � �° � o license Num6er lia Class � . � - ��--�Q_� . - " � � . � � r/7.-�,.�t� Confracfor Da1e . . � � " �� � . �� �3.J�A � v ❑ I am exempt onder Sea � . . . . _ . . � ' #• a • e �$ W Plan clieck fee a 8.8P.C.for Ihfs reason� � b SJ � '� °2�.�� ? PERMIT ISSUING FEE S Date: TOTAL FEE (J7' e e e 2 Q,G O u Signoture OWNER-BUILDER�ECLARATION P�AN CHECK APMICANT .� . � D$�21 -8 6 � I hereby affirm that I am ezempt from the CoNractor's license � , , � law for Ihe followi�g rea5on(Sedion 7031.5,Business and NAME �1 . ' � Profe ' ns Code): � I, os owner of the property, or my employees with ADORE$$ �_ wages as their sole compensation,will do the work and CITY r TEt.NO. �--�� � Ihe slructure is not intended or offered for sale(SeUion - 7044,Business and Professions Code). - � - OWNER a ❑ I,as owner of the prope�ty,am exclvsively coNrading MnR / � � - � wlth licensed[onlrodo�5 fo Construct the projed(Set- qpDRE55 �� N tion 7044,Business and Professions Code).-� - - � CONSTRUCTION LENDING AGENCY �- � �I � � � TEL.N�7�18��� - I hereby affirm�hat fhere iz a mnstrutlion lending agency for , the periormance of ihe work for which ihiz permit is issued � CONTRACTOR '' ' - �- . (Set.3697.Civ.C.). - �-v ... _ ._ _ .... .. ._-_.__ . . _ . , .. . . . AD�RESS Ol1S . . _ . _ _. . .. -. .. . ., ... .. Lenders Name CITY TFI.NO. -�j��G> . _ _ .. _ ' . . .. . . _ . lender's Address � ' � STATE LIG � . I certify ihof I have read this application and state tha�the LiCENSE NO. - CLnSS-� -�- � --- � -- - . - . . _. .._-- ._ . _ . . ._._.__ above info�mation is correct.I agree to mmply with oll County . . . ordinances ond Sfate lawz relating to building construction, � , . . _. . , _ . � . � _ � �and h reby uthorize representaiives oi this County�o enter � � . ' upon he�ve•menfioned propedy for insp tion urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE__ x . 8�/ CL.�CL _ _ _ _ .__. Signature of ApplimN or Agent� - � ate . - .. - . .. ._ . _ . . . . � _ _ =,� � _\- . "f_. `,, '\ 1� . � . � `�� '` , ``i ''� `�S �, �'ti��'i � ���������� �� � ��6 i `` •,`{ 11 • �.' ` `..- �,;` . ` . - t_ ` ' - � � \ � �t ' ��a ...� �+, �'`{' 1\t_ _ '1. �'. ,',t '` . ,'�' �:. A � � ��1� . �. 1 . � . '1� �', 1 � �` - � ' ' ' . . . .. - t � ,. � � `'\' ,11' ,r ' '`�, ,,.� ' µ :a , \ • .,t �1 Q 1 ',' `l. 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