HomeMy WebLinkAbout1397A WORKERS'COMPENSATIONDECtARATION App�ICATION FOR PERMIT -
I hereby aHkm rhal I hove o cerlificate of consem ro self � �
insu�e,or a certificala of Workers'Compensation Insurance, .
or a certified copy Ibereo( Set.3800 b.c.�x � iaosa�c - � NEATING -�VENTILATING - AIR CONDITIONING
Po�i / �/'Q���^�� -CE-81B(REV.10/81) � .
Ocy Ivl�a�-/1-LS�L ompany � � � . . .. .. . .. . ._.
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy is filed witb the tounry 6uflding inspeo- FOR APPLICANT TO FILL IN - - BUnoiNG �7 +
tian deporimeol. � ADDRE55 (i �! r/l,�%' �f�
Date /I l�� T��� �- � . (PRINT OR TYPE ONLY) .
APPlicanl.=�" �`��,_ . LOG\tITY
NO. ttPE OF APPLIANCE OR EQUIPMEM FEE �
� . CERTIFICATE OF EXEMPTION FROM WORKER$'� _ � NEnREST n ��
COMPENSATION INSUkANCE � � CRO55 Si. it�X r
(ihfi ssetion nwd nor bo compt•r•d if ehe work invotvd 6y ^B�arrioru uNir,sTu oisreia��o. PRoceSsco ar
the parmit Is�or one hundred dollars(SI00)or lea.) . �
I cerlify�bat in the performonce of the work for wbith fhis.. A�R HANDtING UNiT,CFM '`^^� `
- permit is iswed,�sholf nm emp�oy any pereon in any manner � D 1' 10.\O� `�
so os to become subject to ihe Workers'Compensation laws.. . BOiLER,BTU nvvaovnts DATE MSPECTOR'S S�GNATURE —
Date opplicant � COMPRESSOR,BTU O vo0 �(j �' ROUGH �
z �=
_ NOTKE TO APPLICANT: I(,afrer making rhis Cerrifimre of VENTILATIONSYSTEM FINAL Z-� � e--�—
Exemption, you should become sobject to �he Workers' .
Compensation provisions of the labcr Code,you mos!fcrtF- - EyqppRqTIVE COO[ER �/j�(��iQT�QN
with comply with such provisions o� ihis permit shall be
� deemedrevoked. - ' � � -- FURNACE: FAU_G YRV - O �� -
LICENSED CONTRACTORS DECLARATION�- � FLOOz BTU / �
I hereby offirm Ihal I om lieensed under provisions of Chapler 9� HfATER: � SUSPEnIDED UNiT_ - -� .
'(commencing wifh Sedion 7000)of Divislon 3 of the 6osiness ' wA« �1 3 9,7 A
and Professione Code,and my licensa is in full force and effed.--" � � / � � -� �z }
� a
. . .
License Number��Lic.Closs � _ _ � . . . ► . � � �� V
Conirattor pote Il 3� . � .._ . . . . . . ► • •5 3 e 5 O .
� r
I am e.empl under Sec • < o J�J,Z J c=i V
Plan check fee "'
Q9.07-86 a
8.8P.C.for ihis reason� � y
Date;
- PERMIT ISSUING FEE S ,� ?
Signotu�e TOTAL FEE
OWNER•BUILDER DECLARATION MAN CHECK aPauCqM �
I�hereby afFirm thot I am exempt from the Contmctor's License� , � ,
Law for the following reoson(SeUion 7031.5,8usiness and rvaME
� Professions Code): � � � � -
❑ I, as owner of tfie properfy, or my empioyees with ADDRE55 �
� wages os the�r sole compensolion,will do the work and � C�rv TEL NO.
the strocfure is not intended or offered for sole(Sec�ion �
7044,Bosiness and Prafession5 Code). ---- . .
OWNER
❑ I,as owner of the property,om exclusively controcting_ �` S. � �
wilb litensed caniractors b mnsiruct the project(Sec- qDDRESS �j / N
- - iion 7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY -- CIN. J.� ' �_TEL NO. S � �
I hereby off�rm ihat�here is a mnsfruction lending agency for ��
� the performance of 1he work for which�his permif iS i55Ued-� COMRACfOR ' "'� -�' - ,
(Sec.3097,Civ.C.J. - _'
� . � ADDRESS ' � � �. " - , ' .. � .. .� .�
LenderiName - � --- - � - - � � - �-� �--
- CITY. . . TEL.NO.����� � _ . .. . . .
Lender's Addre54 � �r��� - - -�
STA7E /IQ ���, �j,�
1 tertify thol I have reod this application and sla�e Ihal Ihe - LICENSE NO.� yp�� -C1A55 � („(iJ, .
obove informatfon in correct.I ogree to comply w�th oll Couny - � - � � � ""�'- '-� �--�� � �--�-•��
ordinances and Sta�e laws reloting�o bWiding construction, � .
and hereby authorize representaiives of this Coumy ro eMer � - � �� -�- -��� �' � -' - - -- - � - �� � -� � � - � � �
- . _.. .. . ...
upon the aba e-menr�oned proper�y for inspecr�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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