HomeMy WebLinkAbout1671A (10) ,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. SEE REVERSE FOR EXPLANATORY LANGUAGE .
, ga� _ --- _ _
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