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HomeMy WebLinkAbout1392A (7) � WORKERS'COMPENSATION DECLARATION • APPLICATION �FOR PERMIT � I Fereby�affirm that I hove a certi(icate of tonsent io seif - insvre,or a certiiicate of Workers'Compensation Insumnce, HEATING - VENTILATING - AIR CONDITIONING or a certif' d co y thereof Sec:3800 lob.C.) 76P.36eG , .�- , _ . . . . , �7 � - CE-818(REV.-10/81) ❑cyN . ��12/ pany /,t ' � .. Certified copy is here6y fornished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the muny bullding inspeo- FOR APPLICANT TO FILL IN eu�to�tvc. )� tion deparimenl. �/1� (PRINT OR NPE ONLV) ADDRESS li�7L� v�• - Date �/I � APPIicaN � "�'- IOCAIiTY � 2 '7 �"z� NO. NPE OF AFPLIANCE OR EQl11PMENT FEE � CERTIFICATE OF EXEMPTION FROM WORKERY � � - NEAREST � /1 ��9 �� COMPENSATION INSURANCE ' CRO55 ST. /1cV - (Thf�sadion na�d noT ba complebd it tha work involved 6y ABSORPTION UNiT,BiU oisiaicr No. veocesseo ar. 1ha permit is for ona hundrad do�lars(SI00)or Isss.) AIR HANDLING UNIT,CFM � O (�(�� \ 1 certify ihot in the performance of the work for which this � '�1�\C�ld 1� - permit is iss�ed,I shall not employ any person in any monner BO�LER,eTU �so as to become subject to the Workeri Compensation Laws. nrvRovats DATE MSGECTOR'S SIGNATURE . _ _, . COMPRESSOR,BN U O �Q UGH ZG �,J � �ote APPlicont � NOTICE TO APPIICANT: If,�after making Ihis Certificate of vENTiIAT�ON SYSTEM FINAL L^J �� ��Ezemplion, yov should become-subject to"the Workers' . VALIDATION � Compensation provisions oI the Lobor Coda,you muzt forth- EyqppRaTNE COOtER � with comply with such provisions or�Ihis'permit shall be � deemed revoked. ' � ' � ' � � FURNACE: FAU G Y /,l - � . . .LICENSED CONTRACTORS DECLARATION FLOOR BTU v � I hereby oifirm that I am licensed under provisions of Chapter 9 HFATER: . SUSPENDED UNIT_ '(tommencing with Section 7000)of Divislon 3 of the Business � WA�� � _ and Professions C de,and my license is in full forte and effect -"- � - a ZZ -7� �� J 9,G A a C 7„ !J J � License NumTber����•Class �'�J " � -- , �� • • • e 8 � � ��"'^� � .. . , . -. O . Conlraclor Dafe � I • �53.25 � W ❑ I am ezempt ander Sec. Plan[hetk fee •' `J a�5� y 8.8P.C.for ih�s reason � = PERMIT ISSUING FEE S f O � 0 9.0 7—8 8 Da1e: TOTAL FEE Signal�re OWNER-BUILDER DECLARATION � alnN CHECK APPIICANi . I here6y affirm thaf I am exempl from fhe Contmdor's License - � . � Law for the following reason(Section 7031.5, Business ond NAME � � � � - Professions Code): � ' - . ❑ I, as owner of the properly, or my employeei wilh A�DRE55 � � wages as their sole compensalion,w�ll do�he wo�k o�d' � �in, TEL.NO. � � . the strutture is not iMended or offered for sale($ection � 7044,Business a�d Professio�5 Code). OWNER ��. ❑ I,as owner of the properry,am exdvsively�oNracNng �i� with licensed mntmttors to mnstrocf the projecl(Sec- ADDRESS � -tion 7044,Business and Professions Code). � . � CONSTRUCTION IENDING AGENCY -' CIiY � �� � �f 7E.NO. s�i��� I hereby offirm Ihaf fhere is a constroction lending agency for r. ihe performCnte of tha work for which this permit is issued-�- �p�,�7RACTOR � ���� � -� - , ., ' _ _ (Sec.3097.Civ.C.). � � � � /C� �- - - ��----- ' . .. . ... - [O! /F' . __ . . __. _ _ �' __��- . -.. •..�._ . . . .._.__... ADDRESS ' Lender's Name • , . CITY f'� . . TEL.NO. 3 � ._ . .. ...._. . _ _ _. _ _ _ _._ _.._ ._ Lender's Address STATE 1 ! �/� ��� /l 7.� I cedify that I hove read this application and stale thot the - LI[ENSE NO. `-[ U V � -- CLA55 Ci(-FJ -- �' - ----�-�- - -' -�- - - �- -�--- ---- - .�- - above informoiion is mrrett I agree ro mmply with all County ordinances and State laws relating to building construction,_ . � -- . . . .. --.--.. -- -- -�-- - - � - � - � � - ond hereby authorize representatives of Ihis Counfy lo enler ' � � . vpoa ie ab e-mM�ioned properly for tnspedion porp ses SEE REVERSE FOR EXPLANATORY LANGUAGE - - zr __ _ _ . _ _ _ . __ _ _ _ _ . _ . Signa�ure of pplimnl or Age�f �°�e ' - � , . r f,..I--'_" ' i . Il 1i,� ��� �,`: ��; . � ��: , . � . , � .. . ' ' . , �3 -' 11, -. , �i 1`� 't' � S , �'`�.. . �� � �� '1 � ; .' _ . N _" ; , .,, !'' . � 1•�,{ — . �.` . � ., . . ',., s. . � , ' . � '.r • ' '7G '� � _ ' . � .. .. � Z �� , �1 —'� , �� . . 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