HomeMy WebLinkAbout1404A WORKERS'COMPENSATIONDECIARATION qppLICATION FOR PERMIT �
I here6y"affirm ihot I have a cer�ificafe of consent to seff
tnsore,or a certificate of Workers'Compensation Insurance, ���� - - , HEATING - VENTILATING - AIR CONDITIONING
ar a certi(ied copy ihereof(Sec.3B00, ab.C.) � �
❑_y '1 /I �� P Y -CE.818(REV.IO/8I) . . . . .
Polit ��6! om an �� - -
Certified copy is hereby furnished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY
CertifieP copy is filed with iha counry building inspeo- - FOR APPLICANT TO FILL IN su���irdG ��G'j �, .
�fion de artme t. � r-, - ADDRESS 7
JA/' (PRINT OR TY7E ONtY)
Data � l' ApplimM '/""�'+� � LO�AtIN �/����
. NO. . TYPE Oi APPLIANCF OR EOUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � .- - - NenueSi
- � COMPENSATION INSURANCE � - . . CRO55 ST. � � �
(Thtf�ection n�ad noT ba completed ff Ihe work�Involved by ABSORPTION UNIT,BTU � oisrzicr r�o. vaocess[o ar
. ��1he permit If for ona hundnd dollars(SI00)or less.) AIR HANDLING UNIT,YFM
I cerfify that in Ihe pe�formance of the work for which thiz '� � �o.\c>�(��Q
— permit is issued,�I shall not employ any person in any manner � —
so as to become subject 10 ihe Workers'Compensalion Laws.. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNANRE
� Dote � Applicanl ' COMPRESSOR,-BTU� "`�✓ 1D ROUGH
NOTICE TO APPLICANT: If, after moking ihis Certificate of VEMILAifON5V5TEM FINAL � �[���
Exemption, you should become subject to the Workers'. -
Cempensotion provisiens of ihe labc+Cede,yo�must ferth- EyAFpRqTiy�cpp�ER - VALIDATION
� with comply with soch provistons or this permi� shall 6e �
' deemed revoked.� � . • � . FURNACE: FAU_GRA I /� - ,
LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I hereby affirm thaf I am licensed�nder provisions of Chopter 9 HEATER: SUSPENDED UNIT_ � �
�'(commencing with Section 7000)o{Division 3 of the Business ' WA« �
and Professions Code,and my license is in full force and effed. I " � F 1 4 Q 4 A d
lifensa Number T��� lic.Class C� - - � � +�. . . . .8 V
Conimcto ��'� lt�Date ���� I • •5 3.2 5 �
� I am ezempt onde�Sec. � � � . -- • • •5 3,2 5� O.
. Plan check fee y
6.8P.C.for�hts reoson _ pERMiT ISSUING FEE S !O 0 9�O 7—a 8 �
Date:
TOTAL FEE ZS �
Signatore - �
� OWNER-BUILDER DECLARATION PIAN CHECK APPLICJINT � � �
I hereby offirm�hat I om exempt from Ihe Conimdor's License � � � .
Law for the following reasan(Section 7031.5,Bosiness and NAME � � �
Professions Code): � � - � � '� �
❑ �, as owner of the property, or my employees with ADDRESS
-- - - � wages os their so�e<ompensation,w(il do the wark and
the strudure i4 not intended or ofiered for sale(Sedion Citt TEL NO. -
7044,8osiness and Professions Code). . . . � . � �
_ . -_ - OWNER �IY�rGQL�
❑ I,�os owner of the propery,am exdusively conlroc�ing - '
wilh licensed contmclors to consfrucf Ihe projed(Seo-� ���
- -tion 7044,Bosiness and Prafessions Code). � � ADDRESS �/'�
CONSTRUCTION tEN�ING AGENCY an � su � �' D� OO
I hereby affirm thot there is a construcrion lending ogency for , .
Ihe performante of tha work for which this permit is issued � CONTRACTOR �� � ' ' �
(Sec.3097,Civ.C.). � .._. . ___ .--'..-. .-.... . -
_ _ .. _
. . . ... A�ORE55 b � __ - ' . . " __ _ . . . .._ .
lender's Name . �
.-. CITY . . TEL.NO. �y ' ._ . ._. .. .__. _ . _ _ __ . _
Lender's Address r' �7� �
�I certify that I hove read this applica�ion and stoie ihot the � IICENSE NO. �-�X QASS- ��W - - .
above information is corrett.I agree lo comply with oll County . �
ordinances and 51ate laws relating to building consfrottion,, ,
.. . . _ .. .. _..
and hereby aulhorize represento�ives of fhis County fo enter ' � � -�-� - � �
opo he abov -menGoqed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��� .. _
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