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HomeMy WebLinkAbout1405A (7) WORKERS'COMPENSATIONDECLARATION - APPLICATION FOR PERMIT � I hereby'afFkm that I have a ceriificete of consen��o self insure,or a certifimre of Workers'Compensation i�5��a��e, . HEATING - VENTILATING - AIR CONDITIONING �� or a certifi d copy thereoi(Sec.3800,Lob.C.� 76A364C _ CE-818(REV.10/81) Policy N��omPon �� - . . . . .. . .. � ❑ Certified copy is hereby furnishe . COUNTY OF LOS ANGELES -- BUILDING AND SAFETY �'�Certified copy is filed with the co�nty building inspec- FOR APPLICANT TO FILL IN qDDa 55 �,S. l� / r/� tion depnarr ent � ....,,��. ��ff �vaiNi oe rrve ONtv) � � ' Da�e� � �` � Applimnt •,�1�-��1V- �j LOCAIITY 7 C� /Z � i NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ���J � - � CERTIFICATE OF EXEMPTION FROM WORKERS' - NEARESi p - COMPENSATION INSURANCE � � CROSS ST. ,y.�' �' //� (This sacflon nood not ba mmpleted if 1he work Involved by . ABSOaaTioN UNiT,eTU OI9RiCi NO. CROCESSED BY Iha pormit Is for one hvndred dollars(5100�o�IaiE.) � qIR HANDLING UNIT,GFM J� '1\ � I cerlify thot in the performonce af the work for whith�his (� 1� 1(� Q� � - ��permit is issued,I shall not employ any person in any monner BOitER,BTU so as to become subjetl to ihe Workeri Compensation Laws. nvraovnts DATE INSPECfORS SIGNATURE - � COM7RESSOR,BN � �� �� '� ROUGH 9�D t_ Dale - ApplimM � . . NOTICE TO APPLICANT: If,after making 1his�CertiPim�e of VENTILATION SYSiErn FINAI r'L' ,C Exemptfon, you should betome-sobject to'the Workeri. Compenzation provi;ions oi thc lobor Codc;you must fcrth- evnPORAnVE COOtER � VALIDATION ' with camply with such provisions or this permit shall be deemed revoked. . � .� � � fURNACF. FAU GRAVITY� - - -/- IICENSED CONTRACTORS DECLARATION � FLOOR B7U ! I hereby af(irm that I am licensed vnder provisions of Chopter 9 HEATER: SUSPENDED UNIT_ - � '(cammencing with Section 7000)of'DiWsion 3 of the Bosiness ' WA« �„ � and Professions Code,and my license is in foll force and effect. � :l � � J/J Z �� 4 Q�p 0 '�JQ '�l CJ 7 ( litense Number�,�yJ� 1-lia Class �.W. . . _. .. ► � V �� �• • • o . '�; p� r Contrattor Date ��� . . . . .. . . - � • •4 9',7 5 V ❑ 1 om exempt under Sec. . . . . a Plan check fee e . .4 9,I�� '^ 8.8P.C.for this reason- Z � PERMIT ISSUING FEE S l� v Date: 09.07-88. TOTAL FEE Signature � OWNER-BUILDER DECLARATION� PtAN CHECK aaauCANT I hereby affirm thal I am exempt from the Contrador's License � Law for the following reason(Section 7031.5,Business and NAME � �- Professions Code): � � ADORE55 ❑ I, as owner of the property, or my employees with � - woges as their sole compensation,will do the work ond-� -- ��rv TEL.NO. ihe siructure is not intended or offered for sale(Sec�ion 7044,Business and Professions Code). � OwNER � ❑ I,as owner of the propery,am exclosively contrac�ing • �'` wiih licensed coMractoro to conslrotf Ihe project(Seo- ��� /��� �� � # fion 7044,Business ond Professions Code). ADDRESS CONSiRUCTION LENDING AGENCY � - CITV' J�- L NO.�i�� I hereby nffirm that there is a construction lending ogenry for , 1he performante of Ihe work for which this permit is issued- �� �pNTRACTOR � - - - " (Set.3097.Civ.C.). / / _ _. .. _ __. _._ : -.- _._. __ _. .._ . . . � - ADORE55- f� !O b J�-. . . . . . ._.. �:: � � ��: �.. �� . . ... lender's Name . _ .. CITY �. TEL.NO. �(� l'� . . . . . ._ . _ . . Lender's Address STATE ` `( ���+, LIC. I ce�tify that I have read this applimtion ond stafe that the� � IICENSE NO. "7'"/ `f � M55 '�-- -��� -�--�-- -- -- - � � � above information is mvect.I agree to tomply wi�h all County ' ordinonces ond State Iaws rela�ing to 6uilding constroUion, , _ . _ . .. . .. _. . - - - .. ._.. _. . .. ond hereby auihorize representatives of this County to eNer � . � � � � ���- �pon r�e above-merrioned property for inspection rp�pr�oses. 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