Loading...
HomeMy WebLinkAbout1410A (7) 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 � 3��� � � Slgnoture of plimm or Ageni �a�e - . _ .. . . . .. . . . � . . .. . . . .. . . . . . .. . ; _,___, --------- � -- ' _'.` 1 ' , , � �, ' ' , 1. ;1 ' '-- 1 r_ �; � �. �_ �,_ � ... . " , - % . • �\ �.�r< �' � 'i � . : �\ i , » �1 I . '. � � 'r •-•--�- . . . �.� • , �:� r 0 4 � i �i � �- . ,, .,��• - �� - ..� , � � , . ,` _ ,;1 ,' l'/ �f �. ..� - � i � � ''��:• � . N :� 'i,f 'I .. ��` . _ - . �' , " ,, �� 1� ' ` ' � ' ') . i ' " ' � _� � �. 1 , � I� . . � ,1' - . . . ..---�--� " , _.. . •�'�T__' . ` � .... .��.. . . ,. . . ... . ^"_• � � �' �, . ; : � �1 �-• , _... ._ , � ,- . ' , _ _ _ . -- ' ,, : . � - � , �I '`- - �, - _ - -- { ,. ' � i " ' . i � � �: � = '�� � , ` � .._ . ,'� _ ,- � ' ' . � � - � i� , Z , � ` �1 - � i` ,' � . _ � 0 j ' , . � ; . � � t , � � , z � , ;, � _ O �' - ,' i : ' � vm+ . r ' : • ' �� � � _ ; • ._ ' - _ -- ' ; -- �. '� - � , ' • , , _ _ �- � ,, . i i . -- •• � . . _. _ - . i � � . _ i ;, < .. - } , ' : - , i 1 . ', - ' • ' �S o o 'o�o o.^0-3��.�a � m m � , _ � . w, •.o 0 3 � f T° m cc �?� N_- � �, m m � 3 N m - , � , . �. � ��.'��.T�.{p 0 �j b A � 0 N ��N � . �- � � �� �:N 4 � . .. � - . ' '" . , . . Q ' � . ' "'0 �I � S'O �n ;� ^ � ,�Q p 7 7C' r�-. �N .�.U' �.�l 7 � S��,C �n in �`< . �1 �i ' _ 7 " O � "�O (y � �� .�n O� � (L 6"� �3 �] A C ' u.�� � N o N =.Q �,� a,F 0 � � .. � 1..' ' . � � . ., ��•. _ n. ' � i Q �''N.N�£.� pc`-2� � q �."�iDW� � p�K��O�.�r��� � �p3.. z . . 3 .. ., orom'so ry ? o ...orN -' o c .m �"n N3'� m . — ;' ° :v ° '" � a« �ov � � '�� f\mo� m�� ° o � A ? � o`-� �» .Cp _ _ . _ �, � �£{3f � > > o =om � 3yN , � x �.NwN � n '" � C � - �, ' 1 ` . / �n . �Q1�1 1 � �De�D � P.��� < ,� ��.ON",0..��5 `C!j�[N..'3 �;� C � , � 03 . ,C7. � u � � . " � .. ' p/ N '1�.< N- n O fD .N N O"O d i➢ �• ..X W�.^ , V C O f tD-. m � . . . ' . . N fP . 0 O �^ 7'O.O..S S� S '� � ��� fl �T n -!1 ' K ` ''D . . ' _ o � , � r.� T°.b 3 m �-a� m.° s`n ° �0 4 n.�,3 °,a-cv Q �m� m p - ,'� _ . �' � f° i�vrop a 'nc � :,c �<� o� 3 ,� �`t'��' Sm � 3O m � �'� n . , o' c ' -, _ 1� � - . - . ^�<H �m�vm�co',? o' N'm" ° �```�'m�° ''`� oo . � ' , • _ � � . . � , ''j ! � `� ° N °'`"Q,�,° �v °.3 n n.£ � a-o-�_1°. n-p'O'uv.''< � 3' ,D -. . _ ' ' , _ . n'a�..�o � p,'O `I�D p �-� a�d p,�p.O'O�N �'D '1➢ C p-� � T � - . ., , . _m o o �3 3 � < � �o o •� 3 3'.o io o co . • ,. . N F a'� � � ' A�f o :a '° °" a 3 < iN.',�:n ,n„ � O `. � � � �° � yn � 0� 3 �Qo.,� T�W .WN �.n.� � o=.m .aj > > 'Z . _ . . _ .D o ��- � �-- � a-3 a°W £ �- 3-a3 N a°" "c �+o � .� - . ' .. �' . . . i 7 N T� S O C N O� (1 O C� N ry .��p N �' O E W�' ' ' " . ' �' . �b�'(lm m � O [l� H O'j: -F '.7'O n'G'O +p � �S�p � , . .. . . _ CQ 1�.'p 7 U..� S, > � 'D .� Q �T) " � d �' S/D rJ S� V' u� � ' - " . . - . . � ' _I _ 5�N.9'��. O CL• � 3 n ��J } p.`• 7 �i �." S m S. , .. � .. , � ... - - 0 O.� ? ,., � a.N � � S� � _� . �--�----�-- 1�