HomeMy WebLinkAbout1681A (10) 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
;
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