HomeMy WebLinkAbout1396A WORKERS'COMPENSATION DECLARATION � �
I hereby offiim thol�have o certificate of conseni to,e�F � �APPLICATION FOR PERMIT�
�nwre,or o certificote of Workers'Compensation Insurance, ,bA3eac HEATING - VENTILATING - AIR CONDITIONING
ar a certi(ied copy ther-e7of(Sec.3800, - b.C.) � CE-818(RFV.�10/81) �
P�o�'�cy N� �2/�omPony - . . . . . . ._ .. .
Certified copy is hereby furn�shed. COUNTY OF LOS ANGELES---- BUILDING AND SAFETY
�Certified copy is filed wiih�he coonry bvilding inspeo- - FOR APPLICANT TO PILL IN BU4DiNG O�
twn deparfinenf ADDRE55 � `/ �
'� Dale '��� APPlicant ' (��NT OR ttPE ONLY) LOCALItt 7�
� N0. TYPF OF APPIIANCE OR EQUIPMENT FEE �^--' ' /
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEneEST�
� COMPENSATION INSURANCE CRO55 57. � /' �•
(Thf�secffon n��d nof ba complefad if tha work involved by ABSORPTION UN�T,BTU DISiRiC!NO. FFOCESSEO BY
fha permt!Is for one h�ndred dollars(5100)or lass.) qIR HAN�tING UNIT,CFM " �
I certify that in Ihe performance of the work for which�hii . . `� �0.\U(��
_ permit is iss�ed,I shall not employ any person in any manner _
� so as io become subjett to ihe Workers'Compensaiion Laws. BOILER,BN APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR,BTU �•
�� V ROUGH
Date °PPIimM � �� �
NOTICE TO APPUCANT: If, after making this Certificate of VENTILATION SYSTEM FiNAI n—Z� �----��
, Exemption, you should become su6jed fo-the Workeri
Compensa�ion previsions of fhe tobor Code,yeu mos�forih- NAFORAiIVE CCALER VALIDATION
with tomply with such provisions or this permit shall be
- deemed revoked. - . ' � - FURNACE: FAU— VITY�— � -�
LICENSED CONTRACTORS DECLARATION��� . FIOOR BN U�� �
I hereby affirm thaf 1 am licensed onder provisions o(Chopter9 SUSPEn7DED UNIT_
HEATER: WA��
'(comrtiencing with Section 7000)of Division 3 of the Business }
and Professions Code,and my license is in full force and effect. � - .Z� a
. ..�itense Number ��� Lic.Closs �`"��-- - � - � � `� J 9 6 A V
. Coniracror��M//� r/'Y Dote ��l 3� � . - . . . _ #• e o • •g O
❑ �am ezempr under Sea � " �5 3�2 5 uVi
Plan check fee , . :5 3.2 b c=, �
B.BP.C.for this reason' pERM1T ISSUING FEE S �O,S� • � � �
Dote: �(�.�'�—�5 a
signoture
TOTAL FEE Z
- OWNER-BUILDER DKLARATION � PLAN CHEIX nvPLIUNi � , �
I hereby affirm ihat I am exempt from the Conrrattor's Literise � � , ,
low for the following reason(Section 7031.5, Business ond NnME
Professions Code): � � - -� �- �
. ❑ I, as owner of fhe property, or my employees wilH ADDRESS � �
woges as their sole tompensafion,will do the work ond CITY TEL.NO. `
Ihe struclure is not in�ended or offered for sale(Section -
7044,Business and Professions Code). � � OWNER - � ' �
❑ I,as owner of the property,am exciusively contmcling �� -
with licensed conlmUorS to mnsiro[t the projecf(Sec- ADDRESS � �
tion 7044,B�siness ond Profe:sions Code). '
CONSTRUCTION LENDING AGENCY cin ��� J,� �h.No.�i/�� �
I hereby affirm thal there is a construdion lending agenty for � , �
the performance of ihe work for which Ihis permit is issoed CONTRACTOR �� �--��-----
(Sec.3097,Civ.C.). �- -'. . .. _ . . . __. .
� - ADDRESS � . . /�.1--�. . . . .... . �_ _-�.,. ;� ' ..
lender's Nome /'U7 � /�
. . . CIN� TEL.NO. /�ll�'f,S� .. .._._ .. ... . .. .. . .... . . ._ . ..._.
Lender's Address
STATE UC. /`
I certify ihat I have read this applimtion and slale that Ihe - LICENSE NO.� � CIASS �(.�'��� - - .-
_ _. . ._ ._. __ _ .. ._ __._.
above informotion is cortect.I agree lo tomply with all County �
ordinances ond Slale laws relating lo building tonstruttion,. .� �
and here6y authorize repiesen�atives of this Coonty lo en�er � � - �� � � � - - � ��- -�� -
upon the above-me �ioned prope�ty ior inspetlion purpos . . - .
'� � �_ � �r_� SEE REVERSE FOR EXPLANATORY LANGUAGE
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