HomeMy WebLinkAbout1398A (7) 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�
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