HomeMy WebLinkAbout1394A (7) WORKERS•�oMPENSAT�oNOE«ARAT�oN � APPLICATION FOR PERMIT ��
I hereby offirin that I have a certi(icale of consenl to self
��S�.E,or o certitimte of Worke�s'Compensafion i�5�,o��e, ,bAa�ac HEATING - VENTILATING - AIR CONDITIONING
or a certif�d copy fhereof(Sec.3800 ab.C.) � .
- CE-81B�REV,10/81) �
. POoli[y N . ��� �ompony�' � . ., . ...� . . . . . . . , . .
Gertified copy is hereby furnishe . COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the coumy buildin9 Inspec- FOR APPLICANT TO F�LL IN BUi�oiNG '7 C /�f����4 Ql�
tio deparimenl. ADDRESS ��J r
I � � --� �PRINT OR T'PE ONLY) �
' Date.l I��' APPlicant. . .� � . � IOCAUTY''��y'L �'�� �
NO. NPE OF APPIIANCE OR EOUIPMENT . � iEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' � - NEnrtESi .
� � COMPENSATION INSURANCE- CR055 ST.
(Thf�setHon naod not ba complatad if the work involvvd by - ABSORPTION UNIT,eTU �ISiRICI NO. FROCESSFO BY
the perm(f is for ona hvndrod dollarz(5100)or Iess.J . � �l
I tertify that in tha performonce of IFe work for which this . AiR HAN�LiNG UNIT,CFM �J m�\���
- , permit is issued,I sholl noi employ ony person in ony manner BOItER,9TU —
so as to 6ecome subject fo�he Workers'Compensotion Lows. � awaovats ontt INSPEQOR'S SIGNATVRE
Date Applitont COMPRESSOR.BTU DO� O ROUGH ��yL� �� �
NOTICE TO APPLiCANT: If, afrer making rhis Certifico�e of VENTILATION SYSTEM � FINAL �2—sZ4' �--�
Exemptlon, you should become subjecl to the Workers'
Compensation provisions of the lobor Code,you�mosl forlh- EyAPORATIVE COOLER VAUDATION
with comply wilh such provisions or fhis�permil sholl be
deemed revoked. � -.� . . - . - FURNACE: . FAU— I � � �
. LICENSED CONTRACTORS DECLARATION � FtOOR BTU
I hereby offirm Ihal I om licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ -
'(commencing with Settion 7000j of Division 3 of the Business WALL � �
ond Professions Code,and my license is in foll force and effect. -� �� �- - �- �z� y
Licensa Numb �L/��� lic.Class��"-" - � � � � - -- V
,� ji�� ► :139.4A p
. Confrac�or pote� � .
� � .. . . . .. _ _ . . . • V
I am exemp�under Sec. �' 0 8 w
Plan check fee o-
B.BP.C.for this reasan� � � � � ^5 a.2 5 z
- PERMIT ISSUING FEE S O
Dare: TOTAL FEE • ^ e 5��5�
Signoture - '- - � -
. OWNER-BUILDER DECIARATION PLnN CHECK A7PlIUNT , O�.G�—S 8
I hereby offirm thot I om exempt from�he Controctor's ticense �
Law for the following reason(Section 7031.5,Bvsiness and NAME � ,
Professians Code}: . �-�-- - � -
❑ I, as owner of ihe properly,or my employees with ADDRESS �
� wages as iheir sole mmpensotion,will do ihe work and � C�iY TEL NO.
�he structure is not inlended or offered for sole(SeUion
7044,Business and Professions Coda). . -� � �
OWNER
❑ I,os owner o(the properry,am exdusively coMracting
with licensed conlroUors to construct the project(Seo- �`�� - /�/ - ��. - - �
� lion 7044,Business ond Professions Code). AO�RE55
CONSTRUCTION IENDING AGENCY CITY � TF.N rn / '�
I hereby affirm thot there is a construction lending agency for ���- J" `�`7�
Ihe periormonce of ihe work for which ihis permit is issoed� � CONTRACTOR�� � �. � � �� - - � ,
(Sec.3097,Civ.C.). . . .. . -- . . _ ..-_ . _._ .
...._ ._---.. . .
. ... ADDRE55 -. . . . .. . _. .
. . ._ . . _ .._ . „ . ... _
lender's Name /Y�/1 !�� -
. . CITY- . �J v/�,�! TEL.NO�-f 7� �^ .__. __. . r . _ ..
lender's Addreu � � �� -� -
SiATE } UG ���\ .
I certiFy�hat 1 have read this app�ication and state that the - LICENSE NO. J -MSS (.r¢� � -- - -- �
. ._ ..... .._.. _- ..
above information is correct.I agree 10 comply with oll Co�nry
ordinances o�d Slate lows reloting to building conshuc�ion, �
ond hereby ou�horize represematives of this CouMy to enter - ��� - - � � � �� - - �- � � - �� � ' - -
u the ab ve-memioned property for insp�e�n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_.
� C.� ��� _ . _ -
S�gnotura of ApPIimM or Agent � �Ie � .- . .. . .. . .- . � ... ... .. .._ . . .. �.. . . . .
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