HomeMy WebLinkAbout1507A (8) WORKERs�oMPENSAT�oNOE«ARAT�aN - APPLICATION FOR PERMIT - �
I hereby�offkm that I have a certifim�e of consent to seH �
insure,or�certiiicate of wo�kers'Compenso�ion Insurance, ���� HEATING = VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,lob.C.) ' � GE•ei8(REV.toi8i) � - � �� � - - .
POolicy No. � Compony - .
Cerrified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county building Inspec- FOR APPLICANi TO FILL IN BunoiNG J�
fiDndepartmenf. � ADDRESS �j�� f�0 �l �p� /e
, _ � � . , �- � (PRINT OR TYPE ONLY� �
Da1a Appiicant � LOCAIiTY . . .
NO. TYPE OF APPLIANCE OR EQUIPMENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'. . NEAREST
' - - COMPENSATION INSURANCE . CRO55Si. �- �j S �N �
(Thfs e�cflon need not ba tomplNed it fha work inrolvod by ABSORPTION UNIT,BTU piSTRi[T NO. PROCESSED BY
� the pormlt t�Ior ona b�ndrad dollars(SI00)or.leesJ AIR HAN�IING UNIT,CFM- lO \�_ _ p
I certify thot In Ihe per(ormante ot the work for which this ��•t�y,
permit is Issved,I shall not employ any person in any manner �
— so as Io 6ecome subjetl lo the Work Compen �Ion w , BOItER,97U � � avvxovn � nr[ INSCECTOR'S SIGNAT�RE
C,�Z�B' APp�_�a�� � COMPRESSOR,BTU ROt1GH / •
Date
NOTICE TO APPUCANT: If, ❑fter moking thls Cettifimte of VENiIIAiION SYSTEM FINAL
� Exemption, yoo should betome subject fo the Workeri .
Campensa�ion provisions of ihe Labor Code,you musl forth- EVAPpRA71VE COOLER VA D�1T16 ^
with comply wirh svch provisions or this permif shall be - � ��T
� deemed revoked. � FURNACE: FAU_GRAVItt - /� v
UCENSED CONTRACTORS DECIARATION �� FtOOR BTU '( /
� I hereby affirm Ihat I om litensed onder provisions of Chapter 9 HEATER: SUS7EN�ED UNIT_ J
'(tommentinq wi�h SeUion 7000)of Division 3 of ihe Business - WA«� T
ond ProFessions Code,and my license is in full force and eHecL � - -- - - - y
�
. �License Number Lia Class , , _ - - � - � - V
K
Confrador Dale � � � � 0
F-
❑ I am exempt under Sec. _,. _ . w
Plan check fee • y
8.8v.C.for this reasorc PERMIT ISSUING FEE S � �
Da�e:
Signature TOTAL FEE �
� OWNER-BUIIDER DECLARATION PtnN CHECK AVM�CnNT - . ,
I hereby affi�m that I am exempt from the Contractor's License . �
law for the foilowing reoson(SeUion 7031.5, Business and NnrotE � �
-Proi ssions Code): -� � � ' '
ADDRESS
I, as owner of the property, or my employeez wiih �� 5 Q 7 A
� woges os their sole compensation,will do the work ond
the shucture is not inlended or of(ered for sale(Section CITY 7EL.NO. � #� • • • •8
7044,Business and Professions Code). _. , � � - - -
OWNER i �- � • •3 0.5 0
❑ I,as owner of the property,am exclusively controcling ' �
wiih licensed toniroclors fo construct the project(Sec- DDRE55 0 �J � ' °3 a J��
tion 7044;Buslness ond Professions Code). �
CONSTRUCTION IENDING AGENCY - - iN � � R �-TE�.No.- �S �Y p q� �_g g
I hereby affirm ihaf rhere is a tonstrutrion�ending agency for �
the performonte of fhe work for which this permit is-issued �pNTRACTOR �(v��� �--� - - `
(Sec.3097.Civ.C.). � .-. .. -- . . . �-. -.
� ADDRESS . .. _ _ . _ .. _ .�::`. . :. ... '
lender's Nome - �
CIN. - . . TEL NO. _._ .
Lender's Address - �-��- � -�- ��
- STATE � � UC.
I certify rhat I have read fhis application and s1a1e that 1he UCENSENo. � - CtASS . . . .
.� . _ _ _ .._._.... . . . _ .. . ..
a6ove iniormation is covecf.I agree b mmply with all Couny . �
ordinances and Stale laws relating to building consiruction, : . �
and b eby authorize repiesentatives of this County lo emer � . - � � � �� �� � �- -� � � �� -� �� -
opo t e above- Ni operty for inspection purposes. SEE REVERSE fOR EXPLANATORY LANGUAGE
. -- .._
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