HomeMy WebLinkAbout1409A WORKERS•�oMPENSAT�aNOF��ARAT�oN � . qPPLICATION FOR PERMIT � �
I hereby affirin thaf I�have o terlificate of tonsent b self �
r�s��e,or o tertlfimfa of Workers'Compensafion i�g�.a��e, ' HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Set.3800 Lab.C.)� 76A36aC .
/,In� CE-818fREV.10/81) . . ... . - . . . .
P❑olicy � Compa . �.... . . . . �
Certified copy�s hereby furnish d. COUNTY OF LOS ANGELES- BUILDING AND SAFETY -
� Ceriified mpy is filed with the county building in:pec- - FOR APPLICANT TO FILL IN BUILOING n,,
fion departmenl. - ADDRESS � � CF/���G/ (�'.
(PRIM OR TYPE ONLY)
Date '� �Applicant � IOCAUN � � �
NO. TYPE OF APPLIANCE OR EQUIPMENT . - FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'. NeaResT /�
� - COMPENSATION INSURANCE - �ROSS ST. i /!/!Y( 7
(Thl�soction noed nol be complatad if fho work Involved by Ae�RPTION UNIT,BTII Di51RICT NO. PFOCESSEO BY �
fhe parml!1�for one hondred dollars(5100)or Iass.J AIR HAN�IING UNIT,GFM �
I certify that in the performance of the work for which ihis '� ma��n C
permit is issved,I ihall not employ any person in any manner -
so as to bemme su6ject ro the Workers'Compensefion Lows. . BOiIER,8TU APPROVALS OA7E INSFECTOR'S SIGNA7l/RE
COMPRESSOR,BTU v� /Q ROUGH 2'� ��----- .
Date applicant � .
NOiICE TO APPUCANT; If, after moking this Cerlifimte of VEMIIATION SYSTEM F�NA� 2— + C4�'
Exemption, you should become sublect ro rhe Workers'
��-- Compensotion provivons of tha Labor Code,�you mos�(or�h- EVAGORATII�E COO:ER UALIDATION
- with comply wfth such provis�ons-or this permit-shall be
deemedrevoked.. . . . � - --�� FURNACE:. FAU�G AVITY /j7
-IICENSED CONTRACTORS DECLARATION FLOOR eTu J�
I hereby affirm thol I om licensed under provision5 of Chap�er 9 SUSPENDED UNiT_ .
�'(tommencing with Secfion 7000)of Division 3 of�he Business HEATER: WA��
and Professions Code,and my licensa is in full force and effetL - � �'
y �7� � � g �14Q9A 4
LlcenseNumber �'�O l Lic.Clau��`-� � _ . - -- , � V
� �• • e •� 0
Controclo� � afe_�� � � �
( se4975 ~
u
❑ I am exempt under Sea � _ . . . . . W
Plan check fee . . � ,
B.&P.C.for ihis reaion' �9'�"' y
PERMIT ISSUING FEE 5 ("� Z
Dafe: - Q 9�0 7—�8
Signoture TOTAL FEE
� OWNER�BUILDER DECLARATION vIAN CHECK APPLICANT . _ . -
I hereby affirm that I am eKempt from the Contratlor's License � � - � �
Law for the following reason(Section 7031.5,Bosiness and � N.4ME � . ,
Professions Code): ' �� � . -
'❑ I, az owner of the properfy, or my employees wilh ADDRESS -
wages as their sole compensolion,will do ihe work and ' �
the struUure is not infended or ofiered for sale(Section CiTY TEL.NO.
7044,Business and Professions Code). � -
OWNER
❑ I,os owner of ihe property,am ezdusively mniracling �
with licensed toMrat�ors b constrvcf the project(Sec- DDRESS / �
tion 7044,Business and Professions Code).
CONSTRUC710N LENDING AGENCY �� GiN ' -" "�" �� T .NO. �. vD
I hereby offirm that there is a conslruction lending agency for .
ihe performance of the work for which ihis permit is issued COMRACTOR -"- �� � ,
(Sec.3097.Civ.C.). . . . . - -----� - -
_
. . ADDRESS . �,� . � � . _ . . __ . .. . -, - .. • . .
lender's Name
cITY r _ .rEl.No.�. � J ._._.. . .._. . �_ . . .
Lender's Address � ��
STATE � /� LIC _
I certify thal I have read ihis application and srote that the � uCENSE NO.��-f� l�� CLASS� � .
- _ . -- .._._ __ .._._ _..
obove informotion is correct.I ogree ro mmply with all Coumy
ordinonces and Stote laws reloting to building consfruUion, _ -
ond hereby au�horize representatives of thiz Coonty to enter � . � � .�- � - � '�- �-
upo ie aboye-rr�ntioned property for inspection pwposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/�� . _
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