HomeMy WebLinkAbout1410A WORKERS'COMPENSATIONDECLARATION ' APPLICATION FOR PERMIT �_
I hereby affirm thal 1 have a cerlificate of consent to self _
insore,or a certHicme of Workers'Compensotion Insurance, HEATING - VENTILATING - AIR CONDITIONING l3
o�a cert/if�ied copy thereof Sea 3800, b.C.) t 76A36eC . .��.
Nql ����m an � CE•818�kEV.IU/81)
O�Y P Y'� ��- . _ . . . .
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified mpy is filed with the county building inspeo- � - FOR APPLICANT TO FILL IN � � � BU�IDwG �
ion departm nt. . �,- (PRINT OR NPE ONLY) ADDRESS / S �!�/f G( /J �
Date �� Applicanl � _ . LOCAtfTV ��'��
NO. TYPE OF APPLIANCE OR EQUIPMENT� FEE
- CERiIFICATE OF EXEMPTION FROM WORKERS: - NEAREST /1 �s7 _ / �
COMPENSATION INSURANCE � � -
CRO55 ST. iZ�( �/iv�lrl�t
(This seclton ne�d nof 6a complatad if tha work involvad by Ag$ORPT�ON UNIT,BTU DISTRICI NO. GROCESSEO BY
� the perm(f is(ar ona hundnd dollorz(5100)or lass.) � AIR HANDUNG UNIT,CFM� /�
I certify iha�in�be performance of ihe work for which rhis �J �`p�� •
— permif is issued,I shall not emp�oy any person in any manner —
� so as to becoma subject to the Workers'Compensation Laws. BOILER,BTU� nvvaOvaiS DATE INSPECTOR'S SIGNATVFE
Date � Appliconf � - � COMPRESSOR,BTU � � (7 ROUGH J �
NOTICE TO APPIICANT: If, afler making this Cerfificate of VEMILATIOt�SYSTEM FINAL )�, .
�Exemption, you should become sub�ect io the Workers'
Compensotion provisior.i of the Lcbor Cede,you must fcrlh- EVAPORATI�COOIER VAUDATION
with comply with such provisions or this permil shall be
�deemed revoked. � �� �. . �� - - � � FURNACE: FAU_GR V Y - - '
� � � . LICENSED CONTRACTORS DECL4RATION . � Flooe BTu .O
� I hereby af(irm thot I am licensed under provisions of Chapter 9 � HFATFR: SUSPENDEo UNIT_ � � �
�'(mmmencing with Section 7000)of Division 3 of the Bosiness ' wAi� �,
and Professions Code,and my license is in full force ond effect. ��" . d
License Number������ Lia Class�� �d. -. .. � , �1 4 1,0 A V
�e • e e •f'y . �
Gt�t� �f�'S/ 30
Conrracror• ��Date l� �5�. - �. . . .. O
� I •�49,75 W
-I am eaempt onder Set.
Plan check fee °�
6.8P.C.for this reoson � � • o �4 g,7 5� Z
PERMIT ISSUING FEE S �
oore: 09.07—F�o
TOTAL FEE
Signature
�OWNER-BUIIDER OECL4RATION PLAN CHECK APPLICAM
I hereby oifirm thot I am exempt from the Controctoi s License� - , �
law for the followfng reason(Section 7051.5, Business and NAME �
Professions Code): - � � � � -� � � � -
❑ I, as owner of the properry, or my employees with ADORESS - .
� wages as lheir sole mmpensalion,will do the work and � Cltt � TEL.NO.
the structure is nof iMended or offered for sa�e(Section -
7044,Business and Professions Code�. , � OWNER
❑ �,os owner of the property,am ezciusively contrac�ing MniL -
with licensed mntracton lo construtl the projed(Sec- qDDRE55 � �/�
� - tion 7044,Bvsiness and Professions Code). �
CONSTRUCTION LENDING AGENCY � ��� � CiTv . . � �'�. L NO.� � .
I hereby offirm tha�there is a constructio�lending agency for ,
the performance of ihe work for which Ihis permit is issued CONTRACTOR � - �
(Sec.3097,Civ.C.). . C . ._ .. __ ..___-. . . __... .
. � - AODRE55 / lYJ L� . . . . ,. . . . .. . . .
Lender's Name
. . CITY � TEL.NO..� STZI� . . _ . __ .
lender's Address �
STATE 1 '' LIC. .
I certify�hat I have read this application and state thaf ihe . LKENSF NO.� �'( � C1n55 � �- � - -� -
... ._ ._ .. .. . ..
above information is correcl.I a9ree to comply wilh oll County
ordinances and S�ate laws relating to building wnsiruUion, . _ . _ _ _ , __,_ _ _ _ _ __ _ _
and hereby outhorize representatives of ihis Coonty�o enter - �
upo 'ie above-meetioned proper�y for inspedion rpozez. SEE REVERSE FOR EXPLANATORY IANGUAGE
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