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HomeMy WebLinkAbout1397A (7) WORKERS'COMPENSATIONDECIARATION AppLICATION FOR PERMIT - I hereby aHkm rhal I hove o cerlificote of consem ro self � � insu�e,or a certificala of Workers'Compensation Insurance, . or a certified copy Ibereof Set.3800 b.c.�x � iaosa�c - � NEATING -�VENTILATING - AIR C�NDITIONING Po�i / �/'Q���^�� -CE-81B(REV.10/81) � . Ocy Ivl�w�-/1-LS�L ompany � . . . . .. �. . .. . _.. Cerrified copy is hereby furnished. COUNTY�F LOS ANGELES BUILDING AND SAFETY �Certified mpy is filed wiib 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.=�" �`��,_ . LOUtITY NO. ttPE OF APPLIANCE OR EQUIPMEM FEE � � . CERTIFICATE OF EXEMPTION FROM WORKER$'� _ � NEnREST n �� COMPENSATION INSUkANCE � � CRq55 St. it�X r (Thlt ssetion naad nof bo compl�t�d ff fhe work involwd 6y . ABSORPTiON UNiT,BTU oisreia��o. PRoceSsco ar ihe parmlt Is�or one hundred doi�ars(SI00)or lea.) . � I cerlify ibat in the performonce of the work for whith this.. A�R HANDUNG UNiT,CFM '�^^� t - permif is iswed,�shoil nm emp�oy any pereon in any manner � D 1' 10.\Q� � so os to become subject to ihe Workers'Compensation laws.. . BOiLER,BTU nvvaovnts DATE MSPECTOR'S S�GNATURE — Date opplicaM � COMPRESSOR,BTU O vo0 �� �' ROUGH z� C�� _ NOTKE TO AP%.ICANT: I(,after making fhis Cerfiflmfe of VENTILATtONSVSTEM FINAL Z-� �f C—�� Exemption, you should become sobject to �he Workers' . Compensation prov'rsicns of fhe labcr Code,you mos!fcrtF- - EyqppRqTIVE COO[ER �/j�(��AT�Qf� with comply with such provisions o� Ihis permit shall be � deemedrevoked. - ' � � -- FURNACE: FAU_G YRV - O �� - LICENSED CONTRACTORS DECLARATION�- � FLOOz BTU / � I hereby offirm Ihat I om lieensed under provisions of Chapter 9� HfATER: � SUSFENDED 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,2 J� 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 mmpensolion,will do the work ond � C�n, TEL HO. the strocfure is not intended or offered for sole(Secfion � 7044,Bosiness and Prafession5 Code). --- � . OWNER ❑ I,as owner of the property,om exclusively controcting_ �` S. � � wilh litensed caniractors b mnsiruct the project(Sec- qDDRESS �,S / N � - tion 7D44,Business and ProFessions Code). - CONSTRUCTION LENDING AGENCY -- CIN. J.� ' �_TEL NO. S � � I hereby off�rm that�here is a mnsfruction lending agency for �� � the performance of 1he work for which�his permif is issued-� CorareACfo2 � -�- -�� - , (Sec.3097,Civ.C.J. - _' � . � ADDRESS ' � � �. " - , � .. � .. .� .� tender i Name - � --- - � - - � � - -� �-- Lender's Addre54 � - �- - CITY. 0�..���. . . TEL.NO.��`��� � - . ._ . . .. . . . . 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 Iaws re�ating�o building construction, � . and hereby authorize representaiives of this Coumy ro eMer � - � �� -�- -��� " � �' ` - -- - � - - � -� � � - � � � - . _.. .. . ... upon the abo e-menr�oned proper�y for inspecr�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � ��??!� �'��� _ Sfgnarure of App�konf or A9em - Da�e �� - - .. _ .. . --. .. . . . . ........ .. . .. . � , ... ....,I.-' ` s! i , '�. ' �, ' f � I • - � ; t/, �,4 � ;�� i t t j- " ' 4 < i �, .. Z �li' ;`� -__.. , ' `•' � .;� � '',,"I ' -- ^ ;5 � 4 � , i-' ''"" �' . .�.' 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