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HomeMy WebLinkAbout1390A (7) 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. 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