HomeMy WebLinkAbout1392A � WORKERS'COMPENSATION DECLARATION � � I Fereby�affirin that I hove o certificafe of tonsent io se�f . � APPUCATION �FOR PERMIT insvre,or a certiiica�e of Workers'Compensation Insurance, or a certif' d co y there�o7f Sec:3800 lob.C.)\ ibi+stec � .- --� HEATING - VENTILATING - AIR CONDITIONING - OtyN . //1�/�Ppn �t � CE-Bf8(REV.-t0/81) � ' . . . . ! Y Ceriified copy is here6y fvrnished COUN7Y OF LOS ANGELES BUILDING AND SAFE7Y � CernRed copy is filed w�th the couny bullding inspec- FOR APPLICANT TO FILL IN eunoirvc tion deparimenL � ADDRESS �/J�/�' O/'� J�I � � -, � ����%_�'/� /J . �L,.., /�� (PRINTORNPEONLV) � Dafe � Ap'plicanr.i 'T� rl�Y LOCJGtt � 2 7 �-z � � . NO. NPE OF AFPLIANCE OR EQl11PMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' � NEAREST � COMPENSATION INSURANCE � CRpSSSt. � �J�lJ [Thf�sadton na�d nof ba complebd{t tho work involved 6y ABSORPTION UNiT,BiU oisiaicr No. veaesseo er. � 1ha permills for ono hundrad do�tars(SI00)or Isss.) 1 certify ihot in Ihe performonce of Ihe work for which 1hi5 . AIR HANDIING UNIT,GFM (�(� ` - permit is iss�ed,I sholl no1 employ any person in any monner . O ''1 1\A 1�1� -so as to become su6�ect to the Workeri Compensation Laws. BO�LER,eTU AVFROVALS DATE INS�ECTOR'S SIGNATURE �ote nppliconl � �� � COMPRESSOR,BTU U O �U UGH ZG �---1 NOTICE TO APPIICANT: If, after moking Ihis Certificate of vENTiIATtON5Y5TEM FiNAL L�� CJ--�� Ezemplion, yov should become-subject to"the Workers' . Compensarton prov�stons of the Labor Caie,you must{oHh- EyAPORATNE COOLER VALIDATION � with comply with such provisions or�Ih�s'permit shall be � deemed revoked. � � � � FURNACE: FAU G Y - � /� � � . .LICENSED CONTRACTORS DECLARATION FLOOR BTU � I hereby otfirm�hat I am licensed urtder provisions of Cbopter 9 HEATER: . SV57ENDED UNIT_ '(tommencing with Section 7000)of Divislon 3 of the Business � �'�'A« � and Professions C de,and my litense is in full force and effect -�� - a - } � � � C 7�, � U ZZ � =� J9GA � license Number�Cl�.Lia Closs �'V , U ,,,/� J��j��j� j��. e8 K . . Contraclor�=�++ �Date� .. . . - • • Q ❑ I am ezempt�nder Sec. 1 • �5 3 2 5 v Plan check fee " .; � �� = a 8.8P.C.for ihie reason� - - a 2 5� y Dofe: PERMIT ISSUING FEE S f O � 0 9.0 7-8 8 = Signar�re TOTAL FEE � OWNER-BUILDER�ECLARATION � MnN CHECK APPIICANi I he�eby affirm that I om ezempi from the Contmcror's License - � � Law for�he following reoson(Section 7091.5, Business ond NnME . Professions Code): � � . ❑ I, a5 owner of the properly, or my employeei with a0�RE55 � � � wages as lheir sole compensalion,will do the work ond� � ���, TEL.NO. � � tfie strucWre is not imended or af(e�ed for safe(SeUion � ' 7044,Business a�d Professio�5 Coda). OWNER � ❑ I,as owner of the property,am exclasively�ontraUing `--'� wilh licensed controttors to mnstroct the projecl(Sec- ��� � -tion 7044,Businesz ond Profezsions Code). � ADDRESS CONSTRUCTION IENDING AGENCY -' CIiY � �� � �f iF.NO. s�i��� I hereby offirm Ihat�here is a constr�ction lending agency for �1 ihe performCnte of tha work for which thls permit is issued-�• �p�RACTOR ��— ,�// '�'- � - - (Sec.3097.Civ.C.). ' . . -a��.c • . ._ _ ... ._.. .._.. . . - ADDRESS �/- _ .._ ' __. � � .�.. .. . Lender'sName �` /'4 � �' � .. ._ �.�..� . �.. ..."- . � . ��TY r� . TE�.N�. ,�J � . .. ...._. . _ . _ _ _... Len er'sA ress -� " - -� - �- STATE l � �/� 11C, /l 7-� I cerlify that I hove read ihis opplication and stale thot ihe � LIfENSE NO. �( Uy � � CLA55 Ci(..Q) -- .� - -.__.._.. _ -. ... . . .. .___ _._ _ - a ove informoRon is mrrett I ogree to mmply with oll County - . ordinances and Stafe laws relming�o building construction,.. � and hereby authorize represematives of Ihis Counfy lo enier ' - . � � - �- '-�"" �- -� -�-� � - � � vpaa ie ob -mM��oned praperfy for inspeUion porp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE. _zr- _ _ _ . _ _. Signa�ure of pplimnl or A9ent Dole .._ . . - . . -. . . . .. ... ....-. .. . . . . , � I- ;- i--` -- ._, .`-__ _ ...i ' ; . ;.' i: � j: . _ ; i - ; m ' -- � . i . I .. ' '`. ;.' i, -. � �'+ � ,I .� ` , 1 7p , . � . . ; � , -. 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