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HomeMy WebLinkAbout1389A (7) 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_ _ D Signolure oi ApPlimnl o.Agent � Doie ... . . - . ... - . - •.... . . . . .....___ . _ .. _._. _. _ . . .. . �r�� � � i 'i� �) • . �--` `� �, 1 ; � i ' �` .., �` s` 1,' , • '� `� , , , ,�.. �. 't� '1�, �` - '. , �1 � - , �. , _ ��A '� � 1 ' �`-- • ` � �1 . _ . . ^1� ' � ` � \ '1 � 1 . - � 1 � . ,'y � _•' '` e,f•� � ; � '' r; � .�. 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