HomeMy WebLinkAbout1391A WORKERS'CONPENSATIONDECLARATION �. - APPLICATION FOR PERMIT � �
I hereby affKm thol I have a tertificole of consent to self �
inwee,or a certificata of Workers'Compensonon Insurance, HEATING - VENTILATING - AIR CONDITIONING ��
or a certtfled copy fhereof(Sec.3800 ab.C.) � 76A364C ' ' .
^� CE-S18(REV.10/BI)
O�y ��12/�ompony � . -- � .. . . . ....._ _ . .
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the coumy botld�ng�nspeo- POR APPLICANT TO FILL IN .eWtDiNG 7�j
�fion par e . � AD�RESS (j L � li���� Q�i
Dat�� (PRINT OR TYPE ONLY�
Applican �' � tOCALiTY #(�2 � �
NO. NPE OF APPLIANCE OR EQU�PMENT FEE
�CERTIFICATE OF EXEMPTION FROM WORKERS' -_ � NenaesT //�
COMPENSATION INSURANCE � . CRo555t. �i� (vC
(Thfs sat}ion naad nat be eompisfod IF iho work fnvolved 6y . Ag�RPTION UNIT,BTU DISIRICI NO. FROCESSED BY
The permlt Is(or ona hundnd dollars(5100)or IessJ� � � � '1
I certify 1ha1 in ihe performance of the work for which this. AiR HnNDIiNG UNiT,CFM
� permil is issued,I shall not employ ony person in any manner � ������ —
' so as to become subjed to the Worken'Compensotion lows. gOIIER,BTU AVGROVAlS DATE INSKROR'S$IGNATURE
� Date Applicant � COMPRESSOR,BTU �r �7J �U ROUGN Z �'�
NOTICE TO APPLICANT: If, oRer moking thi5 Certificote of VENTILATION SYSTEM FINAL �[y �"/--------
� Exemption, you shovid become sobjed to the�Workers;
Compensoiion provisions of rhe tabor Code,you mVst fonh- EVAPORAT�VE COOLER � VALIDATION
with comply wi�h such proNsions or this permi�-shall be
deemed fCVOked. � :� - ' �. - . � - FURNACE: FAU_G I7V / �
. ' LICENSED CONTRACTORS DECLARATION� . FLOOR BTU
I hereby affirm that I am licensed under prbvislons oi Chopter 9 HEAiER: SUSPENDED UNI7_
`(commencing with Section 7000)of Divisian 3'of ihe Business �'A«
and Prafessions Code,and my licensa is in full fort and effect. � - ZZ � � n'
C.� r �
License Nomber � `�lia Closs� �� �� � V
�/i,/, /�-�, / ► O
Controcror "'��� r��J Dare 1�j�� . - � - �� v�� A �
V
� ... _ . . . . . • e W
I am ezempt under Sec. Plan theck fee �•' ° •� y
B.BP.C.for this reason' Z
PERMIT ISSUING FEE S � 1 a •5 3,2 5
• Da1e:
Siqnature TOTAL fEE ,� � a 5��Jr`
OWNER-9UILOER DECLARATION PtnN CHECK AGPUCAM �
I hereby affirm that I om exempt{rom the Contractor's license � ,�9�7—�'8
Law for the following reoson($edion 7031.5,Buziness ond NAME -
Professions Code): � - � . _
❑ I, as owner of the property, or my employees with ADDRE55 � - .
- � � wages os their sole compensation,will do the work and � � �
� the stroctore is not intended or offered for sole(Section � C�TM TEL.NO.
7D44,Business and Professions Code�. , -�-- � � -
OWNER
. ❑ I,as owner of the properfy,am exclusively conlracting
wilh licensed conirodors 10 cansfruct 1he projed(Sec- ��� "-� -�
- tion 7044,Bosiness and Professians Code). � - /DDtiE55
CONSTRUCTION LENDING AGENCY ---�� Cltt � -�L FL:NO. �J'�J � �
I here6y affirm that fhere is a consfr�ction lending ogenty for , �
the performance of ihe work for which this permit is issued� �- COMRAROR , --- � - --'- -- �
(Se�.3097,Civ.C.). - � . ... . .. .... . ___. .. _.
. .... ... .. . .� ,
ADDRE55 .... ._ _. . ... __ . .' : .. .�. . . . . . .. .
Lender's Name �/ �-y�
QTV � �.� TEL.N0.��7�• ✓ YJ _ __ _ _ _ . ._._ _. .. . _ . _ .
lender's Address
STATE , I UC.
I certify that I have reod this opplicolian and slale Ihat ihe UCENSE NO.� `'� � CLA55 � � �-��� � - � � ---- - ' �-��� - - - - . .- _.. __t. .
above ioformation is correcl.I agree ro comply with all Counry
ordinantes and State laws relating ro 6uilding construUion, � _ , _ _
and hereby aulhorize representatives of this County to enter� '� � - ��� � -� � � -� �� - ��
opon th abov -mqmioned properry for inspectton Gpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _
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