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HomeMy WebLinkAbout1671A ,WORKERS'COMPENSATIONDECLARATION . APPLICATION� FOR PERIY�IT � I hereby affirm�hat�have a certificate af cansent to self . � � � , insure,or a ceriificate of Workers'Compensation�nsurance, HEATING • VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec.38D0,Lab.C.) - ���� ' � - PHC 0506� Golden E cE-e,e caev,ioisq P❑olicy No. mpany �e Ins.. . ._. . . .._ . . . Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Q Certified copy is filed with�he mony building inspeo- FOR APPLICANT TO FILL IN . eUi�oiNG tion deparlment. ADDRESS 735 Pantera Drive r� 29-89 7��CI30 A].T IIIC. (�INT OR TYPE ONLY) `�`ITY Dalc� APP���aRf 1 � NO. TVPE OF APPUANCE OR EQU�7MENT . FEE Diamond Ba.r TP8Ct# �1Z H2 CERTIPICATE OF EXEMPTION FROM WORKERS' .... . NeneEST � � COMPENSATION INSURANCE ' ' � CROSS ST.LOT�( rj JOb# S 6 (ThI�sedlon noed not be tompletod if 1ha work involvad by AB�RPTION UNIT,0TV DiSfRIR NO. NtOCESSEU BY the permit ls for one hundred dollors(5700)or lass.) - � qia NnN�twG uNii,-CFM ` /, �(� t I certify that in the performance of the work for whith this 4 �/ 1' 10.`017 `a permit is issued,1 shall nat employ any person in ony manner BOiIFR,BTU — so as fo become subjed to the Workers'Compensotion Laws. , nvvxovnis onTe INS�E TOR'S SIGNATURE � . 1 COMPRESSOR,BTV 60.000 ZO OO ROUGH � Da1e � �1PPlicanf . NOTICE TO APPLiCANT: If, after making this Certificate of � VENTILATION SYSTEM � F�NAI Z -. �mption,�yoo should become subject to the Workers' npensation pro�isions of the lobor Code,you muSi{Oftfl- EypppRATIVE COOIER VALIDATION . � with tomply with such provisions or this permit shall be ' de0med revoked. � -� .� -.� � . .- FURNACF. FAI➢� a,�y�TV � � � � � UCENSEDCONTRACTORSDECLARATION�� ' 1 FLOOR BTU �VU•�— lO OO � � I hereby affirm that I om licensed under provisions of Chap�er 9 HEATER: SUSPENDED UNIT_ �'(commencing with Section 7000)af Division 3 oF fhe Business � WALL ond Professions Code,ond my license Is in full force and effed, � - -- y" 13 Re isters @ 1.7 Ea 22 6' License Number 380�5li3 ' i��.�aosg' �-gg - - � - � ► � �1 6 7,1 A v m ContrattorRanrhn Air� Tnrnote g-31—�T_ ' �'� � � � `8 0 ❑ I am exemp+under Set. I �n 5 3 2 5 uVi Plan check fee n- 8:8P.C.for this�eason _. pERMIT ISSUING FEE j �-O-S� • • 6 5 a G 5� 2 Date: Siqnotore TOTAL FEE 2 0 9 2�—8�' � OWNER-BUILOER DECLARATION- . � n.aN CHECK navuCaNT I hereby affirm that�am exempt from fhe Contractor's License- � , ► - � - Law for Ihe following reason(Secfion 7031.5,Business and NAME � . . - -P^rofessions Coda):- -- � ' - � - � ���� `i I, as owner oi the property, or my employees with A�DRE55 � _ , ) wages as their sole compensation,will do the work ond the structure is not inlended or offered for sale(Settion CITY , TEt.NO. 7044,Business ond Professions Code).. . �� -� - � OWNER. �e.�DdeII CiP011 ❑ I,as owner of ihe properly,am ezclusively contracting wi�h licensed confradors lo tonslruct the project(Sec- pDRE55 107�+ Parkview Drive�1I201 • lion 7D44,B�siness and Professions Code). � CONSTRUCTION LENDING AGENCY ' CITY � COV1II8� ���N�� $1S-9F)7-9rj�F I hereby affirm that there is a conslruclion lending agency for ► . Ihe performance of the work for which ihis permit is issued-- �OritanRoz �g�0 �R IftL•. (Sec.3097,Civ.C.). � � . .. -__. .., . ._. ..__--- --- -- �- . . ADDRESS - . _ . .. . . .. �.:... , ..- -___._...__ .__ .. Lendei s Name � � arv. Up�g rei.Non�+-981-4801 _ . __ Lender's Address � � � STATE LIC. I certify that I have read this applimlion and state that the. - UGENSE NO.3BO �3 CLA55 (,'-20 - �- � � —�� � - .. . above information is conect.I agree to comply wi�h all Coon�y � - ordinonces and Staie laws relating fo building tonsfrucfion, _ _ and hereby authorize repre:entatives of this County to enter � � � � - ����� �-��� ' �- �� � ' � � upon e a ove-menlio d properry for inspectian purposes. 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