HomeMy WebLinkAbout1681A WORKERS'COMPENSATIONDECLARATION , � . APPL'CATION FOR� PERMIT � I hereby offirm ihat I have a certiHmte of consent lo self �nsure,or a certificate of Wo�keri Compeniotion Insurance, HEATING - VENTILATING - AIR CONDITIONING � or a certified copy Ihereof(Set.3900,lab.C.) 76a36aC . PWC 05061� Golden Eagle Ins. �-B�B�REV.10181) P❑olicy No. ompany . .. . . _ - . Certified copy is here6y furnished.- COUNTY OF LOS ANGELES BUILOING AND SAFETY _� Certified copy is filed withihe toonty bvilding inspec- . � FOR APPLICANT TO FILL IN . � BUILDiNG � tion deporiment. . . � AD�RESS , (PRINT OR TYPE ONLYJ Da�e 5-29-59 � Applicant RSL1Ct10 A1T� TI1C. NO. TYPE OF APPIIANCE OR EQUIPMEM FEE ���ITM D18TROIIC�. B$T Tract# 42582 � GERTIFICATE OF EKEMPTION FROM WORKERS' cR059 9r.LO'1.'IS 15 Job/f 876 ' ` - COMPENSATION INSURANCE � . .(Thts s�eflen naad nof bs eomplN�d it ihe work Involvad by ABSORPTION UN�T,BTU ois�Ricr No. veo[[55eo er - }he pe�mli(s for on�hundred dollars(5100)or leos.) AIR NANDLING UNR,-CFM I cerfify fhat in ihe performance of fhe work for which this-. �,� ��},�Q(�� permit is issued,I shall not�employ any person in any manner BORER,BTU ^ - so as fo become svbject to the Woikero'Compensa�ion Laws. � nvvRovnis oare INSPECTOR'S SiGNAfURE � 2 COMPRESSDR,BTU 36.000 ZO OO ROUGH Date Applitant . NOTICE TO APPLICANT: If, after making this Certifimte of VEM�tATION5Y5TEM FINAL _t , �xempiion, you shou�d become subject�to the Workers' ompensation provislons of the Labor Code,you must forth- - ¢vnvOennvE eoo�eR - � VALIDATION � '�'wlth comply wiih such provisions or this permit shall.be - deemed revoked. - <�� - ' ��. � � �� � ,� FURNACE: FAIDC�.Fi6:WLY�_ ,ZO QO � ' � LICENSED CONTRACTORS DECIARATION � � FtOOR BTV t�U UV - �I hereby affirm fhot I om licensed under provisions of Chopler 9 HEATER: SUSPENDED UNIT_ . . '(commencing with Section 7000)of Division 3 of Ihe Business WA« ' - and Professions Code,and my litente is in full force and effed.'"- - " �- - d 15 Re isters @ 1.75 Ea 26 2 �i b 8.1 A � License Number 380543 Lik CIOss C-2D � � - - � � . V ConiracforR8I1C1'10 A1S� II1CDate�5-31-89 � . . , �e � e • •8 O � a I am eaempt under Sec � � . � . . _ . . . I •�•7�7 5 uVi Ptan check fee a 8.8P.C.for this reason' � 10 50 ' °°7�'7 5� Z - - PERMIT ISSUING FEE S oo,e: 09."e0-88 Signalure TOTALFEE 76 75 OWNER-BUILDER DECLARATION RAN CHECK APPLIfANT . . ' -' . I here6y affirm Ihal I am eaempf from the Conlmctor's License . , � Law for fhe following reason(SeUion 7031.5,Business and NAME � � � . Pnroiessions Code): � � :'iJ I, os owner of the propery, or my employees wifh ADDRESS . - , wages as thair sole compensafion,will do Ihe work ond-" the slrudvre is not in�ended or ofiered for sole(Setlion ��rv TEL NO. 7044,Business and Professions Code). � - - - � -- - � OWNER r�e Anden Gro ❑ I,os owner of the properfy,om exclusively tontrocting l� wilh licensed co�1m[�ors to co�slruct�he project(Sec-� � DDRESS�-074 P3TIiV�@57 DP1V@ �2��. � , � �tion 7044,Business and Professions Code). �� CONSTRUCTIONIENDINGAGENCY -- �-� CRY-- COV1I78� TE��N��S1S-J67-95�1. . I hereby affirm thal there is a ronstrucuon lending agency for � the performance of fhe work for which this pe�mit is itsoed� - GONTRACTOR R��� �R �C. . � ►_ (Sec.3097.Civ.C.). - � � . .---—� --..... . ., . �--� - �-- . . . . __ . A�DRE55� -ZZ3Z W. 9t11 StP@0't . . . .. . .. _ -. .' . '.'_ -� . . ' Lender's Nome . � CITY . _�1c1IId . TEL.NO. '�].4-(�81-I�80 . . . Lender's Address � � � ���- - � -� ��� � _ I certify tha�1 have read fhis opplicoiion ond siale that fhe . IICENSE NO:.3SOJr�►3- � CLASS �'' 20 � obove Informo�ion is correct.I ogree 10 comply wifi all Counry . , . �� ordinon[es ond State laws relaling�o building consfrudion,- � ond hereby aulhorize representatives of fhis County to enter � � � � � � � �� � � � - � - - - � -� �-��"�"- - upon t e o ve-meniio d p�operly(or inspection purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE ; , ���,r,o ��y g� $ignalureaf�AppllcanrorAgenr Daee . � - . . . . . - ..-... .. ...-� - '� ' . . '--_'_ �1, ' ,t 4 . . .. 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