HomeMy WebLinkAbout1395A � WORKERS•�oMPENSAT�oN oE��RAT�oN � APPLICATION FOR. PERMIT �
I hereby'afircm thcl I have a certiFico�e of consent to self
insur�,or a certifcate of Workers'Compensation Inwrance,. HEATING - VENTILATING - AIR CONDITIONING
or a certifi d topy thereof(Sec.3800, ob.C.) )6A35<C .
I/�Z71 • cE-aiecaev.ioiei)
� P❑olity ompeny /�i . _. .. _ . .
Certified copy is hereby furnishe . COUNTY OF LOS ANGELES - BUILDING AND SAFETY
��Certified copy is filed with the touny building inspeo- FOR APPLICANT TO FILL IN Bui�oiNG � s' ���, �'i
hon depor men1. /,�J (pRIM OR TYPE ONtY) AD�RESS �
�Dat�I�� ' APPlicant '✓ � c LOCALITY (.�257 �
NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' � NEaREST
�� � � COMPENSATIONINSURANCE' � CROSSST. �
(Thif�ectton naod not be tomplefed if fhe work involvad 6y _ ABSORPTION UNIT,BTU �iS�R�Ci ruo. Prsoc[ss[o ar
the parmif Is ior one hundred dol�ars(SI00)or lass.) 1 D �Q\p��
AIR HAN�IING UNIT,CFM L
I cerlify that in the performonce of the work for which this..
- � permil is issued,I shall not employ any person'in ony manner gOILER,BtU - —
so as to become tubjecl lo Ihe Workers'Compensa�ion laws. _ 'I .+crcovnis DAtE INSpEQOR'S SIGNATURE
. COMPRESSOR,BTU Y���� /� ROUGH y a
Date Applicant �
NOTICE TO APPLICANT: I(, ofler moking this Certificote of�� VENTILATION SVSTEM iINAL r2 c� �G-
Exemption, you shoold become'sabject ro the Worke�s' _
Compensotion prbvisions cf tho labor Ccde,ycv musl fcrfh- �/qFpRqiiV[COOLER VAUDATION
�winc �omply with soch provisions or this permit shall be
deemedrevOked. � - � � � - FURNA�E: FAU_Gq�A1�JY /T .
� � � LIGENSED CONTRACTORS DECLARATION FtooR BTU �o v .
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: . SUSPENDED � UNIT_ � '
.'(commencing with$eUion 700D)of Division 3 of�he Business WA«
and Professions Code,and my license is in t�ll forc ond effetl. }
�1�.3�1 '? Z °u
Litense Number Lia Class� � . ► �1 3 9•5 Ci
ri:��- �
Contractor Dale �• • • • •£j 0
V
� I om exempt under Sec.� � _ - - � - � � - � • ��J.zi,C Jr a
Plan check fee �n
B.&P.C.for ihis reason _. PERMIT ISSUING FEE S !d e o ^5�,?_5� �
Daie: TOTAL FEE_ S3 Z� 0 9.0 7—8 8
Signature
OWNER-BUILDER DECLARATION � PIAN CHECK APPLICANT .
� I hereby offirm that I am eaempt from the Contraclor's License . ►
Law for the foilowing reason(Section 7031.5,Business and NAME
Professions Code): - ' - � � - --
❑ I, as owner of the propery, or my employees with
ADDRE55
-� �woges as their sole compensotion,will do the work ahd �in, � TE� NO �
the structure is not intended or ofiered for sole(Section
- 7044,Business and Professions Code). � �. OWNER ��� �
❑ I,as owner of the property,am exclosively contrading �� / ^/
with licensed conlrat�ors to conshutf Ihe project(Sec• � ADDRE55 �
tion 7044,6usiness and Professions Code). '
CONSTRUCTION IENDING AGENCY � - ` �Itt ' - " f� .�NO.� - �,�
I hereby affirm�hal there is a tonstruttion lending agenty for
fhe performance of the work for which�his permit is issued � �ONTRACTOR � � � �� , .
(Sec.3097,Civ.C.). ._._ . . . . -. .". -.- . ...
. � ADDRESS. . __ � . ._. _ ... .. .. .. . _. �.. _ -t. . .. . . _ _ _
Lender's Nome -
CITY . . . TEL NO.'l� - - �- - � -
Lender's Address STniE ( ��/�.(� UC. q � �
I certify that I have read Ihis application ond state thal Iha IICENSE rv0.��y 1"....5 7 CLA55 �r�W -� �-� —� � ---� --------- - -- -- ------- - � �
above information is mrrect.1 agree to mmply wiih all County .
ordinantes and Sto�e laws rela�ing to building constrodion, _ ,� _ . . . . .. ..._. . - . ' . .
and hereby oothorize representatives of Ihis Coanty to enier . .
apon e obove-men�:aned property for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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