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HomeMy WebLinkAbout0878A �,. ��WORKERS'COMPENSATIONDECLARATION App"CATION FOR P�RMIT fr(/�/' � I hereby.affirm that�l have a certificate of tonseM.ro self Y, '� �x �nsote,or a c�rr�fimta oi Worke.s'Compensotion Insurance, �bA3��. = HEATING - VENTILATING - AIR CONDITIONING r� or a certified copy thereof(Sec.3600,Lab.C.) �.B16(REV.�10/81) � POolicy No. � ComPany - _ � � . . Certified copy iz here6y(ornished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY � Certified copy is filed wi�h the tounty bvildi�g Inspeo- FOR APPLICANT TO FILL IN BUILDING � �f�. fion deporlment�, . (PRINT OR TYPE ONLY) ADORESS �2 'ff.(J7�j��/N .C/i Dote � Applicant LOGALITY � G NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � � � COMPENSATION INSURANCE � Ca055 Si. ATH�lNv L'—/2 (Thl�eecllon ne�d no!bo completad if fha work involrad by ABSORPTION UNIT,BTU DIStRtCi NO. FROCESSE�BY tha parmtf Is for one hundrod doilars(SI00)or lass.) . J J • , AIR HANDLING UNIT,CFM I certify that in Ihe perfo�monca of the work for which this � permil is iss�ed,I shall nol empioy any person in any manner gp�tER,B7U � so es to become subject to�he Wor n'Com ensoiion�aws. nvvRovnis � on7e .i PECTOR'S SIGNA7URE - Dafe o_��-�7applitont GOMPRESSOR,BTU ROUGH �� . NOTICE TO APPLICANT: If, ofter oking t i icat of � VENnIATION SYSTEM FINAL Exemption, you should become subje t to �he Wo erz' Compensatlon provistons of�he Labar Code,you must for�h- Evnroenirve COOteR VALIDATION � wilh.compiy with such�provisions or this permit shall be deemed revoked. � � - FURNACE: � -PP.0_GRAVIN LICENSED CONTRACTORS DECtARATION . . FLOOR BTU , I here6y affirm fhat I am licensed onder provisions of Chapter 9 ' SUSPENDED � UNIT_ - : � '(commencing wifh Section 7000)of Division 3 of fhe Bvsiness � HEATER: WA�� . ond Professions Code,and my license is in foll force and e(feU. � __� .r/J r.. � � � G - y (J�..t.�-tiGo. ✓ Q . license Number � - Lic.Class � � �J � . lv � , , . � CM�-<il. Coniractor pote � � -- --� - -�- - � - '' � 1 � ' �OSZ8A � I I am exempf under Sec. �� _ , ,. ,._ __ � Plan check fee �.'j. y ,$ B.BP.C.for this reasom � Dme: PERMIT ISSUING FEE S c� I • •2 5,7 S Si nature TOTAL FEE 9 sd��5,75�� OWNER-BUILDER DECLARATION MAN CHECK APPLICANT �� � � I hereby aFFirm thaf I am exempt from fhe Contractor's license � ��� 9�'8 7 law for�he following reason(Sedion 7D31.5,Business and N/uaE —. . . Professions Code): . � - . � . . �1. I,as owner of the property, ar my employees with AooRess r� - woges os�heir sole compensation,will do the work ond ��n, ��� - TEL.NO.,.�—� Ihe structure is not infended or o{fered for sale(SeUion' �� 7044,Business and Professions Code). � � � .,�- �f - � � � OWNER �Q.N�L� E• ���YLSI�7V L ' - ❑ I,as owner of Ihe property,am ezdusively conhocting y� � with licensed controctors to conslruct Ihe projecf(Sec- � qpDRE55 I�I� ��I/VCY • l�-p� ' tion 704d,Bosiness and Professions Code). - , '. CONSTRUCTION LENDING AGENCY �-- CiN �' � " � - � � � -7EL NO.��3 j/c� 1 hereby affirm that there is a constrodion lending agenq for , . the performance of ihe work for which this permit is issued CONTRACTOR =:(�����/L � � �� -�- �� � (Sea 3097.Civ.C.). - - -� -- -. . - . . . . � ADDRESS �� �Y-�'l,yL(�h_ _ .'� - �� _ ._._ _ _. _.. _ _.. . ... Lender's Nome . pN ' . . . TEL NO._ . __ . .. .. . . . . ... . _ Lender'S Address � SiATE UC. ' , - I certify thot I have read thfs application and sfate that the UCENSE NO. � - CtA55 ----- --.� � _ .__... .__ .... ..__. _ .._ __ ,.:�- .- - -_ . obove iniormafion is torrect.I agree to comply wi�h all County , � � . adinontes and Staie laws relating fo building construction, � . . ond hereby authorize represeMa�ives of ihis County to en�er ' � �- -- -�� /u�on�he apove-mentionye 'prop for tnspection purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE t '�!� � �S^/S� fST _ _. . / . . ,. � ��-.licant or Agenf - Do�e . . . . . . ..� _ ... . . .. . - .�. .. ..� . .. ��� �� \ , - � _ .... ; �, r��; � ' j , � z - ; '`' �, +'' `} ',1• '" ; '..�,♦ i �. t i �. � /' < ' 'r a �_.,,,;`' . . � . � � , iy � 1 i , i�j . � i. � t t yf .M i �w y , � % r'.. . . �• . •' . ' �11/� '... �, ~. -.i�� 11 � - " � �� .1. - 1 . . . ,i ��, t' � � � �. . �� i � ._ __ , ` t .: Z ' ' - �:: ' , :_ ��� � � � '�:� ,. '� , '.' . 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