HomeMy WebLinkAbout1398A WORKERS'COMPENSATIONDECIARATION APPLICATION -FOR PERMIT � �
I he�eby�affkm that I have a certificate of consent to zelf
insure,or a certificate of Workers'Com ensa�ion Inwrance, HEATING - VENTILATING - AIR CONDITIONING
or a tertified copy thereof(Sec.3800 , b.C.) t 76n364C - � . ,
(� CE-8I8(REV.10/81) '
.POolicy � ��lCompany � .. .
Gertified copy is hereby furnished. COUNTY OF LOS ANGELES eUILDING AND SAFETY
�Certified copy�s filed with the counry building inspeo- FOR APPLICANT TO FILL IN BVIl01NG �.P�/,
/tioide/ / parlment•� , ....���� , (PRINT OR TYPE ONLY) ADDRE55 lI /�K ���
Date/ '1� Applimnt LOCAUTY � v�
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF ExEMPTION FROM WORKERS'- - � NenaE57
� COMPENSATION INSURANCE � . CROSS ST. Q- O/A�
(7hls secllon n�ad not ba complatad iF tho work Involved by-- ABSORPTION UNIT,BTU DISi4iC1 NO. �ROCESSED eY
tha permk it!or ono hundred do�lars(t100)or less.) qIR HANDLING UNIT,CFM
I certify that in the performance oi the work for which�his •
- permit is itsued,I shall noi employ any person in any manner gORER,BTU —
�� so os fo become subject to the Workers'Compensalion Laws. [ ( .l aovrrovnis onTe INSCECTOR'S SIGNATl1RE
. � r COMPRESSOR,BTU _I 6�N' (J Z� � ROUGH
Date APPlicant -
NOTICE TO APPUCANT: If, ofter making this Certi(icata of VENTILATION SYSTEM F�NA� 'z _
- Exemption, you should become-,subjecf 10 the Workeri .
� Compensation provisions of the Labcr Ced^,you must forih- NAPORAflVE CCJtER VALIDATION .
�with tomply with such provisions or ihis permit�sholl 6e �
deemed revoked. � � �-- � � - � FURNACE: FAU_G AVITY-
LICENSED CONTRACIORS OECIARATION � FLOOR BTu .(� �
I hereby af(irm ihat I om licensed under provislons of Chapter 9 � HEATER: SUSPENDED UNiT_ - - �
'(commencing with$ection 7000)of Division 3 of the Business WA«
� and Professions Code,and my license is in full force and effecL- � O}.
(�(/(/�./�jC_ ,A 22 7S o
Licensa Nomber�_I—lit.Class `"' � � . � " � , <� 3 9�{{ V
GG
�ifr<-��� � � �. : . . .a �
Controctor� � -�ate
❑ i om e.empr onde�Sec: ' Plan check fee ' � • `5'3.2 5 �a
B.BP.C.for�h�s reason PERMIT ISSUING FEE$ �� • ��5 3.2 5� ?
Date: TOTAL FEE 0 9,0 7-8 8
Signotora
OWNER-BUILDER�ECLARATION � � PLAN CHECK APPIICAN7 , � - �
I hereby ofiirm that I am exempt trom the Contrador's Litense �� ,
Law for the following reason($ection 7031.5,Bosiness and NAN:E �
�Profenions Code): - � � ' �
❑ I, as owner of Ihe prope�ty, or my employees with
A�DRE55
- woges as their sole compensotion,will do the work ond ��TY . 7EL.NO. �
the shucfure is no�intended or offered for sale(Sedion
7044,Bosiness ond Professions Code). . py,rp�ER -
❑ I,os owner of Ihe property,am exclusively tontrocfing � / � �
with licensed conlrotlor5 fo conslrud Ihe projeCt($ec+ qDDRESS �
tion 7044,8usiness and Professions Code). � .
CONSTRUCTION LENDiNG AGENCY � - }
� CITY... S�TFL.- O. �Y�v -- .
I hereby offirm�hat there is o construction lending agency for
ihe performance o(the work for whith this permit is issued COMRAROR - � - - �- � ►
(Sec.3097,Civ.C.). . / ._._. __._ _ .. . _. .. ... . . .
. . . . .. AD�RE55_- �� LB/�MD✓iC _ . . . .. . _�� ._..'. . �.: .'__ . . ..
lender's Name � �
� _ . CITY _ TEL.N0.�3�' � . _ .._ __ __ .. . .
.._. ._ . . ._ _.
Lender's Address .
STATE / ' r� IIC. /�^�_
I cerlify that I have read Ihis appliwtion and stote that the LICENSE NO. K y -C1A55� ` -- - - - � - -� - - --- , - � � -
a6ove information is correU.I agree b tomply wi�h all Caunty
ordinances and Slate laws relating to building construdion, _ . � . � . . . . _ _ _ _
. . .._ _ ._ _.. ._ __ . __ _ ....
and hereby authorize representalives oF ihis Counry to eNer - �
upo e obov-ment�oned proper�y For ins�ec�purpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ __
D�l� o�
51 noture of APPliconl or Ageni . Dale . . . . . . - � .. .. - . .' _. .. ._ .. . .. . ._ _. ... ,.
--. -, --- -- --- .- i._--
; ; . : ; i i
. � ; � ; .;
� . !; ' ; "• ,j -
, �. .
. -, �
; '
; - � �-�� ;
� !._ j . i ;, ; -
o �� -, �;, , _: � � ... � --
Z �;, ; ' --- ; i ' ,
N ' ��� � � � - � "�. �� � ��� -- � .
. : , . � :.. ^. .
, . , - j. .� •_• � _� .
� i � � � .I. .. ,_. .. ..
. .. i - .. � _ , . . ` � � , .
� � � . .. � � � � � � � � ,
..
.
.
fl._'__ ._-' .. ' . .. _ � " _ - - - ...
. .....__ . .._. ...-_._.. ... ..-..., _.� ..._ ..-- __. .__ _. _ . . - . ... .
` . . , . � _r � '. . ' i , - , � . ' . ! j �
. . I ' , �I i^ I �1 � . � :.
. , , i �
• '. � . _ . . . �
. , .. . ,. , � '�, • : , ,r' , • „ R
� � 'I� If I �: � j ' I '" _ " ' _ _ _'_ ' w' .
I, ' ' ..� ' - 1- i; i i I , �..', ,
� i ` .. , .1 � � , � �
I • i � I , i t._ �. i +, I i i ' Z d .
� � j - m
� - - I � � ' - ; O
y , (.- I i . J , ' N
�I
i
Z
. i
t . � � . t _ � , 1 . � , 0
i '
� i 1 ' , ' . . ..
. ' . " ' "_ _ ' .
. ' - �. � �I ' _ i � � ,
� i ' . , f . - - .: I _ _
I , " ' . I . � - � I � , - . ' ' . � . . . � ' . .
. ' ; _ . � , , ,� ..-' �_ .. . • • �..' , .. . -
�. � ' Q v � w. — , �.c�Eoinp -� o ° 3 � fF.oi.� T 0000•�• �o3c ° 'o ���. -
� � � ' �0 n ?"y-N ' � O S 1 �D N .3 4a �,O ,' � �D . .fl.w rj .
, : . ' . " � � (D . . � 3 �-O N !� -� Q'lD� � 7I"O In !i �^ O �h� � + tD iD �:> > � � . .
. ' . , � v.. � , ?� cn,o'Q ❑ ` ' � �_'°�.�o� ❑N .o' u'�;na ,�, �."omM � c
" ', _ n m ' �°. ry u v f - °-c 3 °-3 ��;a c w n�-o c.�o o' ° A�,o 0 0�
. o W
_ o..." 3 . n ^ p m co�-o °. m' ° m a� w co ° o^. ' "'`"o''~"�'°'�° �� a f-•^ �
� � - . 'O ' O a�1 r-N — � .. 0,^O r N'_1 O . �.`C W;O- � b,� ,� � . ' .
,' _ _ � , �. � N o � 0 3 _ � � o u, f .. _o,o �•� � . � 3ie3 Z
. - `" a , '_a-vaNN � aFo � ° 3n,,N �°- �'�o ;b..m�Oo�'. m ��c ' ��-p :�
' _� � i �. _ � . � , Q� : (� I �, � p�,< N o a� m < a o m ° N � c'u-�. .°"o �.��N�,�n O c'p-o � _ ' �. . -
� � .,. 1 . � . ' O : - N ' '. � O,N > > p,.. �.� F. � 0.���_,�[L� T �--�.�.s: O�=4U m N N o Q r . "
I , - ' - - � ; n � ° ?° v3,rn 7�'° �`' Q, ro�m °.o •,k:= f� n'v � no3 . p . -
�_ : ( _ - - - , o^ 'o �'m S o g o a-o �.�:,� 'a"� ? � o £ m.., m
;� ,._ . � � f � �� N� o � QO ._ N Wb N °`°a � °" 3 °.'o.cv o�,,�� m- � ,:
�. .. _ i . _ , . _ . .O j K.N N.� C a� �S Q�N �-m �Q ?b..S� , �i O... � 3, :� _ .
- ' ` - ' _�o ° N o<.� =m o :�:o � �� a 3 ,c-�-m m�' o 3 0�� �o� '� n
��: . . _ ' � --� o .n m �° m�b ��.�-n`° f .`° � <'o:m"°�.a '" �•� o a-.. � �
• • � `� F� o� 3 No °.� � a;� �'oa oo.:0.o3o� �H-3o�'c � 3, D . „
, _ ;._ - m o � n c x o < $ � f n - ° ° �o 0 3 H 3 0' .o 0 0 0 ��.. , _1 .
. . ..a, m � n > >-3 Tm. fl T n-�:o" 3 � H �_� n � �
. J - . _ , �� � a m T'�-^ ��� v? a°.�fD 19 m � o'��a� a o�a a_c o o. �
� <" Y m c H o,.o ' £ �- a^_.o �u m � ' 3
- : . o:�o °�° ' ° °c° `H° 'o °.• -x- � m �,,� z,,� � n,�3 <'.,0
� ` - � - ��N�,' o' ,, r ��� � ' � �; .o �a� .�^� o° g �o ° °..s�"
o'
� o� � n � a�'o o � : ° � m b o N. N '�'o m ?^ ih�,
o' .� dm �-�c d 2=3 Tm �--