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
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