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HomeMy WebLinkAbout0950A WORKERS'COMPENSATIONDECLARATION � , . APP',ICATION FOR PERMIT ���35 � I f�ere6y affhm�hat I hava a ceriifitale of consenl io self insure,o�a certificate of Workers'Compensalf n Ins rante, �� - • o�a ce�rifie opy thereof(Sec. 00, .C �6A36ac - �.- " HEATING - VENTILATING - AIR CONDITIONING CE-918(REV.10/8I) PoIICY N� ny . ❑ Certified copy is hereby(urnished. COUNTY OF LOS ANGElES � BUILDING AND SAFETY��/��j �Ceriified copy is filed wilh fhe county boilding inspec• � - FOR APPLICANT TO fILL IN � BVILDING fi ep rt nt. � ADDRE55 (PRINT OR TYPE ONLY) Da�e Appliconf �L NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ��A��TY CE TIFICATE OF EXEMPTION F WORKERS' NEnRESi COMPENSATION INSURANCE CROSS ST.�- — � (This�acflon n�ed not bs compla}ed(f fha work involvod by- ABSORPTiON UNiT,B7U oisraicr No. ( cco eo er � tho permft la for ona h�ndrad dollors(SI00)or lasf.) q�R HANDLING UNIT,CFM � � I certify iha�in th8 performance of ihe work for which this � �� permit is issued,I shall not employ any person in ony manner ' so as fo become svbjecl lo the Worke�s'Compensation Laws. BORER,BTU 0 AiFROVAlS � �ATE INSPECTOR'S SIGNAiVRE � Date Appliconl COMPRESSOR,BN ROUGH NOTICE TO APPLICANT: If, af�er moking this Cerlificale of VENTILATION SYS7EM FiNaL � Exemplion, you should 6ecome subjecl to ihe Wo�keri Compensation pravisions af the lobor Code,you must forth- EvavORATIVE COOLER � � VALI ATI with tomply with s�ch provisions or this permit shall be �� deemed revoked. . � � FURNACE: FAU T ._l - � LICENSED CONTRACTORS DEC(ARATION FLOOR BTU " � ^ I here6y affirm thot I am licensed under pravisions of Chap�er 9 SUSPENDED UNiT_ - �--� HEATER: WA�� '(mmmencing with Seclion 7000J of Divisfon 3 of�he Bu9ness _ and Professions Code,and my license is in{ull force and eifect. . - � � [,���(�[j /� /�� a License Num r�LsBGl�-L—Lic.Class�o'1- .. . .. . � V ��`��-g , � ❑Commtb � � �o�e i� � / .. - t� �I om exempt under Sec. . • Plan check fee - a � B.&P.C.for ihis reasom �/f - PERMIT ISSUING FEE S � � oale: Signatore TOTAL FEE. . � OWNER-BUILDER DECLARATION PLAN CHECK APPLiCANi � � %O 9 S,O A I hereby affirm ihot I am ezempt from Ihe Controdor's License � � {�• • • • •8 . low for ihe following reoson(Settion 7031.5, Business and NAME. � �Professions Code�: � '� •.�J��p ❑ I, as owner of�he property, or my employees with ADDRE55 - . � . . wages as their sale compensa!ion,will do the work and '' • •�Q r'.n.,� Ihe slrucfure is no1 intended or offered for sale(Secfian CITV TEL.NO. 7044.8usines5 and Professions Code). 0 a� 7—�8 OWNER ❑ I,as owner of�he p�operty,om ezclusively conhacting � � wiih licensed mnrroUors to consrroct�he project(Sec- ��� ,a tlon 7044,Bosiness and Professions Code). AD�RESS - . CONSTRUCTION LENDING AGENCY � CI TEL.n10. � I heieby ai(irm ihat lheie is a conslr�ttion lending agency far ' - the performance of the work for which this permit is issued CONTRn R - �� �-� (Sec.3097.Civ.C.). � , ....- - -.. . . . .. . .. � . ... . ADORE55 � ' O .. . � � �. . _ _ Lender's Nome �"� �� � � � CITY .TEL NO. �/ lender'sAddress � -� - � � �" �" � - �-- �- - I certif �hat I have read�his a lication and s�ate tho�the STnTE LIC. Y PP LI('ENSE NO. � .�CLA55 U . . .' ' - . . ._ ... ' above informalion is correct.I agree fo comply with oll County ordinances and Slote lows relating Io building consl�uclion, and hereby authorize repre eniatives of this Goumy to enter � � � ' � � � " ��- � �� � � - �� � � upon+he a ove- e i e roperty ior inspectian purp�ojses. SEE REVERSE FOR EXPLANATORY LANGUAGE � p _ . 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