HomeMy WebLinkAbout1035A (5) 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 _
_ _ _ .__.
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