HomeMy WebLinkAbout1393A (7) WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PERMIT � �
I hereb'y affirm�hat I have a cerfificote of conseM lo self .� �
insure,or a cerrfimie of Workers'.Compensation Insoronce, 76A3e�c � HEATING - VENTILATING - AIR CONDITIONING
or a cerhfi d mpy fhereof(Sec.3600 ob.'C.)�- �_818(REV,10/Bl) �� � - - ��� � �-'� �- �
Ocy N� �/27/ ompany .`.. .. . _._ .
Certified copy is here6y furntshe . COUNTY OF LOS ANGELES - Bl11LDING AND SAFETY
11�7��Certified topy is filed wit6�he county build�ng inspeo- FOR APPLICANT TO FILL IN BUIIDING i1 / 1�
7- tiOn deportment. � ADDRESS C/ � y/f�C� i
�����('�' .n (PRINT OR TYPE ONLY)
' Date��_Applicant �+-� lOCnliiV (�'��� . `z
NO. NPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � - CROSS 5T. � `�.
� � COMPENSATION INSURANCE
(Thls soction need no1 be complNed ff fha work involved by ABSORPTION UNIT,BTU �ISiRIC!NO. PROCESSED BY
tha pormit is(or one h�ndnd dollan(5100)or leis.) � . � '^'
AIR HANDLING UNIT,CFM �� !1 - ` " R�U��
•� I certify thot in the performonte of the work for which this �J � � �
�-�permil is issaed,1 sholl nof employ ony person in any monner BOILER,BTU
- so os to become sub�ect to the Workers'Compensalion laws._ nroaovnis DATE INSPFCTOR'S SIGNAiURE
DGIe ApPlicant COMPRESSOR,BTU � /� ROUGH 'f}� ���
NOTICE TO APPLICANT: IF, ofter mnking Ihis Certifimre of VENTiLAiION SYSTEM FINaL ��j��
Ezemption, you sfiould become s�bject to the Wo.keri
Compensotion provisions of the Labor Code,yo�musf forth- EVAPQRATIVE COOLER VALIDATION
� with tomply with such provisions or ihis permit shall be
�deemed revoked. �� � � � � � � FURNACE: FAU_GR VI � �
. ' UCENSED CONTRACTORS DECIARATION �� FLOOR BTU oOD . `D
� I here6y affirm that I am licensed under provisions of Chapter 9 SUSPENDED - UNiT_ �
HEATER: wA��
�(commencing with Section 70D0)of Division 3 of the Business �
and Professions Code,and my litense is in(ul I force and effect: � --� � - �7 �� ' a
r/ / ]�.� � � O
license Number `�� � lic.Class�- � - - �� . -� � , - V
'�� �,,� �134.3A �
Contractor � ate��t-- . - . . •
�;. . . . .g o
� ❑ �I am exempt ander Sea . , , _ , ' w
Plan check fee � , ,�'a 2 5 y
B.SP.C.for this reason PERMIi ISSUING FEE$ � �
Date: • • +5a25�
TOTAL FEE_ ZS 0 9 0 7-II 8
Signafure � �
. . OWNER-BUILDER�ECLARATION � aArv CHECK nvrucnNT � -
I hereby a(firm ihot I om eKempt from the Comratlor's license � '
Law for the follow(ng�eoson($ection 7031.5,Business and NAME � � � � -
-� Professions Code�: - . . � ' .
❑ I, os owner of the �ro er aDDeE55 ' .
p p 1y, or my employees wilh
- ��woges as their sole mmpensation,will do�he work ond .
ihe s�ructure is nol infended or offered for sole(Settion CITV TEL.NO. � .
7044,Busfness and Professions Code). , `
OVJNER ,
❑ I,as owner of�he p�operty,om extlusively coniracfing �
wilh licensed mnlraUors to tonstrotl fhe project(Sec- ��� � �/ � �
� tion 7044,Busineis and Professions Code). . ADDRFSS � !�
CONSTRUCTION LENDING AGENCY - CITY � TEI. O.�5��/�
I hereby affirm thot there is a mnstruction Iending agenty for � ► �
the performonte of the work for whichJhis permit is issued CONTRACTOR �� " - �� -
(Set.3097.Civ.C.)• � � - � - _- �.-- ____...: . . . .
- ADDRESS� . � � ' . .._.. . � :�' . . ,�,� . ..
'
� lender's Name )�
� ._ CITY ..TEL.NO.FJ�Y��a . . _ . .. . . __ .. .
Lender's Address
S7ATE 1 lr/ LIC. �J-�
I certify Ihat I have reod this applimlion and slate that ihe IICENSE NO. �1 f - �QA55 � � �,/ � �
. . . __._ ._. .._..
obove informotion is correct.I agree ro comply wirh all Coonty �
ordinonces ond S�aie laws relating to bvilding constroUion, ' -
and hereby authoriza representafives of this Counfy to enter � � . � � - � � �� � - �-� � - � �������- �
upo 6ove-mentioned property for inspecfion pur�os s. SEE REVERSE FOR EXPLANATORY LANGUAGE �
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