HomeMy WebLinkAbout1389A WORKERs�oMPENSAT�oNOE«ARAT�oN j :� � � ApPLICATION FOR PERMIT �
1 hereby offhm�hat I have a cerlifitote of mnsent b self
�„s��e,or a cerrificate of Workers'camPe�sario�i�:��a��e, 76A7�� HEATING - VENTILATING - AIR CONDITIONING
or o cerfified copy thereoj,(Sec.3600, ab.C.� � /� �� � �
, �,'n -7�( /�/��CE-B18 fREV.10/81) . .. . . . .-- . . � .. . �
,. acy N6�C�Y r z7��C`ompany v v` ._ . . . .
Certified copy is hereby f�rnished. COUNTY OF LOS ANGELES -. -- BUILDING AND SAFETY
�Certified topy i:(iled with the county building Inspeo- - FOR APPLICANT TO FILL IN�- -� � eUi�D�NG je�.� ��
tIioIn deparf ent. ADDRESS pG
Dale ��APPlica 1�. (PRINT OR TY7E ONLY) Ip�ALIN(� ,-7S
� NO. TYPE OF APPLIANCE OR EOUIPMENT - . FEE "4� � `--� �
CERiIFICATE OF EXEMPTION FROM WORKERS' � CR059 Si F- � �T
COMPENSATION INSURANCE -
(Thlt secflon no�d not ba complatad II tha work involved by� /+B�RPTION UNIT,BTU p15TRlCi NO. PROCESSE�BY
tho permff li(or ono hundrad dollors(SI00)or lass.) q�R HANDLING UNIT,CFM
I certify that in the performance of the work for which this � �O rnq�d�-�
- permit is issoed,I shatl not employ any person in any manner gO�IER,BTU —
eo os to becoma subjeci to the Workers'Compensation laws.. nrPaovaw DATE INSVECTOR'S S�GNATVRE
Date� � Applitont' � COMPRESSOR,BTU O � O � ROUGH _Z��' �---'��
NOiICE TO APPLICANT: If,after moking this Certilica�e of VENTILATION$YSTEM � FINAL -�� G7'��
Exemption, you should become subject fo tha Workeri.
Compensafion provisfons of ihe Labor Code,�yoo most forih• NAFORATIVE COOLER VALIDATION
with comply with svch�provisians or this permit shall 6e
deemedrevoked. . -�- � FURNACE: FAU_ VITY�-_- O . �
� LICENSED CONTRACTORS DEQARATION �� FLOOR B7U �'
� I herehy affirm Ihat I om licensed under provision5 of Chapfer 9 HEATER: SUSPENDE� UNIT_
'(mmmencing with Section 7000)of Division 3 of the 9usiness ' 'NA«
ond Professions Code,and my Gcense is in full force and effect.-�' - � -- �- � �7�� �- q
�� O
License Number��lic.ClazsC—� . � - � �- � ► �1 3 8 9 A V
�n/ ', OG
Conirattor "T' � Date�1,�� . . . �e • • s o 8 �
❑ I arti ezempt under Sec. ' � . e 5�2� V
Plan check fee W
8.8P.C.for this reason� r l = a
N
PERMIT ISSUING FEE S /O S� • • ��a 2 S� ?
Doie: TOTAL FEE Z d 9,Q'I—�,H
$ignoture
. OWNER-BUILDER DECLARATION � PLAN CHECK APPLICANT � �- . �
I here6y affirm ihat I am exempt from ihe CoNracror's Li[ense� , . �
Law for the follawing reason(Settion 7031.5,Business and NAME �
Professions Code): - � . ""�
❑ I, as owner of the property, or my employees with ADDRE55 �
- wages os their sole compensation,will do�he work and ��TY - t�i.No.
the sir�cl�re is no1 Inrended or offered for sale(Sec�ion �
7044,Bosiness ond Professions Cade). . '
OWNER -
❑ I,as owner of the pioperly,om extlusively contracting
with licensed contradors lo constrott the pro�ecl(Sec-� ��� � .
- - tio�704G,Business and Prolessions Code). ADDRE55 � .
CONSTRUCTION LENDING AGENCY �� Ciry� � ��� .p�p. '��/��'
I hereby affirm�hat Ihere is a conslruction lending ogenty for � ►
�he performance of the work for which this permit is iss�ed �pMRACTOR
(Sec.3097.Civ.C.). � ... . . .. .
- . . . ... .. ..
� J ...
aooaess - _ _ --_. -.
Lender's Name
� . CITY �� . .. TEL NO. L/�� � . _. . . . . . .
Lender's Address �
S7ATE ' `p��/r. UC. ^7�
I cenify rhat I have read this�application and stare that the tICENSE NO. `i 6 y �CLA55 -^"W � � -- � -
__ .
above information is mireU.I ogree to comply with aIl Coonry
ordinances ond Stote laws relating to building constr�c�ion,
and hereby aothorize represento�ives of this Coonly to en . � � �� - - � - � ��� � � � � � ��� -- � - � �- --�- �
upon bov �entioned properry for�sp�npurp es. SEE REVERSE FOR EXPLANATORY LANGUAGE_ _
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