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HomeMy WebLinkAbout1396A (7) 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 . . - . 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