HomeMy WebLinkAbout1390A WORKERS'COMPENSATIONDECLARATION . APPLICATION FOR PERMIT �
I hereby offirin thoi�have a cerlifimte of tonsent to self
insure,or a ceruftcate of Workers'Compensaeon Insorance, �6A36ac HEATING - VENTILATING - AIR CONDITIONING
or a certified mpy thereof(Sec.3600 ob.C.)� � �- .
n CE-B18(REV.10/81).' .
vr�oli'cy N � / ompony COUNTY OF LOS ANGELES -. BUILDING AND SAFETY
LJ 'Certlfied copy is hereby fumishe .
� Certified topy is filed wi�h�he couMy boildin9 inspeo- FOR APPUCANT TO Flll IN BUitDiNG /�' [
tion dgpar me t. �� /1 (PRWT OR TYPE ONIY) ADDRE55 % .�J /L� �
Oole �1 � Appliconr �d% �OCnuTv Z .� ��
. NO. TYPE OF APPLIANCE OR EQU�PMENT FEE
. , .CERTIFICATE OF EXEMPTION FROM WORKERS'� . � CRO55 ST. � �
� COMPENSATION INSURANCE
(This sedion n��d no1 ba eomplHad if fhe work involvad by ABSORPTION UNIT,BTU DISiRIQ NO. YROCESSED BY
.iho parmlT i�(ar one hundrod dollan(5100)or la�e.) qIR HANDLING UNIT,CFM
I cerfify thot in the performonce of the work for which lhis `O �G\U�..Q
permil is issued,I shall not employ ony person in any manner gpILER,BTU
— so as to becoma sub�ecllo the Workers'COmpensalion Laws. /' Aroaovnl5 onrt INSCFCTOR'S SIGNAiURE
COMPRESSOR,BTU v�� /U ROUGH q
�afe °PPlicant Y 2� �—
NOTICE TO APPIICANT: If, ofter making Ihis Certif'¢ate of VENTIlAT10N SYSTEM F�NA� a— ��
Exemption, you should become��sobjed lo-the Workers' .
Yompensation provisions of the lobor Code,yoo musf Iorth- EVAMRATNE COOLER VALIDATION
-witk comply wiih such pro�isions or this�permit shall be
�-deemed revoked. � - � � � � �- FURNACE: FAU_G viiv � " - .
� . �UCENSED CONTRACTOR$DECLARATION - FIOOR BTU D
I hereby aHirm fhaf I am licensed under provision5 of Chopter 9 HEATER: SUSPENOED UNIT_
'(tommenctng wilh Sec�ion 7000�of Divisi6n 3 of the Businesz WA« }
and Professions Code,ond my litense is in full force ond effect � � - . - � � y
license Numbrl����3�.�. Lic.CIaS� � � - . - � ' �1 3 9,0 A K
% //��e
Contrector Date � - �
Q {�.. . . .g �
1 am ezempt under Sec. w
Plan check fee" 1 •<5 3.?_5 a
B.BP.C.for thts reoson� �^ -
- - PERMIT ISSUING FEE S J- . , .� �_ �
Dote: 3�J"
Signarure TOTAL FEE Z 0 9.0 7—8 8
� OWNER-BUILDER DECLARATION RAN CHFCK APPLI�ANT
I hereby affirm thol I om exempt from ihe ControUw's License � �-�� � �
Law ior the following reo50n(SeCtion 7031.5,Business ond NAME �
Professions Code�: ' � � - �"
❑ I, os owner af the property, or my employees with ADORE55 �
wages as their sole compenwtion,will do�he work and '
� ihe srroctura is not in�ended or offered for sale(Setlion CITY � TEL NO.
7044,Business and Professions Code). . . OWNER �
❑ I,as owner o(Ihe property,em exclusively confrocting �"
with licensed coMracfors lo to�struct fhe projec�(Sec- ADDRESS �. /�
• tion 7044,Business and Professions Code). ' �
CONSTRUCTION IENDING AGENCY �- �' CIN�� �"� � T�.NO. v� �
- I hereby affirm that Ihere is a consiruttion lending ogency for � _
Ihe performance of the wo�k for which this permit is issued�� CONTRACTOR � � -� �� �- -
(Sea 3097,Civ.C.). � � -- .._ . _ .. _.____._.. _......
� - - ADDRESS . _ _ _ _ . . . __...._ ..' '_ `(� . ,.. �- _.'_ _'
�. ._ . . ..- _'_ _'__._ .
Lender i Name
- . .. CITY TEL.N _.. _ . .__.. . _ _ .
lender'sAddress ' ��� -� - � � � -
STATE r� LIC. r�,,�
I te�tify�ho�I have read ihis opplicotion ond state that the- LiCENSE NO. �`{-" QASS ^vV .. . . .-. . .
_. ._ _... __.
obove informmion is mrrect.I ogree ro comply with all Couny - �
ordinances and Sro�e laws rela�ing to building construcNon,, � , __ . _
aod hereby authadze representatives of rhis Coonty to enier ���-� � - �
upo 0 ove•ipentioned property fo '�pett on purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE . _
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