HomeMy WebLinkAbout1399A WORKERS'COMPENSAiION DECLARATION �
I bereby affi+m�hot I hove a�e,,,�;�afe oF�o�se�„o,e,{ � APPLICATION FOR PERMIT
insvre,or a certificate of Workers'Compensatipn Insurance,
or a ce�tified copy thereof(Sec.3600,� b.C.) . �6A3e�c � - HEATING - VENTILATING - AIR CONDITIONING
cF-aie�a[v.iaiery
O�l' � � ompany / . _ .
Cer+ilied copy is hereby furntshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�p�9��/'Certi{�ed copy is filed with ih`youny building��sPeo- FOR APPlICANT TO FILL IN euuoiNc (� ����ry ��,
/—� tion depar merlt. ADORESS
�/ / (PRIM OR 7VPE ONLY� �J�
Date �e APPIi[ant r � LOCAUtt � ^�
� NO. TYPE OF APPtIANCE OR EQUIPMENT � � FEE L �
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEneEST /1
COMPENSATION INSURANCE- ' � � CROSS Si. /j,(�4� f—J�!�
_ (Thi�t�eflen nnd not 6o eomploiad ti}h�work Involvad by . �+BSORPTION UNIT,BTU � mSraiC�tio. veoCeSs[o av
}he permtf(s(or ona hondred dollars(SI00)or less.) . �� � �
I certify Ihal in ihe performance of the wwk(or which this AIR HANDLING UNIT,CFM
permil IS i55ued,I Shall nol employ any pei5on in pny manner a 'O� �Q
so as to become subject to the Workers'Compensation Laws. BOIIER,BTU APPROVAL$ oart INS�ECTOR'S SIGNATURE —
Date� ePPp�a�� � � �OMPRESSOR,BTU I ` V D� !V � ROUGH 6 ��
NOTICE TO APPUCAN7: If, afler moking this Cenificate of VENT�L4TION SYSiEM � FlNAL �
Exemption, you should become subjec� �o the Workers' �
Compen5olion piovisions oF Ihe Labor Code,you must forrh- EyAppRpTiyE�oo�ER VALIDATION
wiih tomply with svch provisions-or this permit sholl be
deemed revoked. � � � FURNACE: FAU_G A Tl'—_. �
� -- LICENSED CONTRACTORS DECLARATION I FLOOR eiU UJJ �
" I hereby affirm Ihaf I om licensed vnder provisions of Cbapter 4 SUSPENDED UNIT_ �
HEATER: WA��
� '(commencing wirh Section 7000)af Division 3 of 1he Bosiness '
ond Professions Code,and my Iicenee is in full forte and effed.-"- � �.
t/ ZZ 7 n-
license Number 7� Y3�� Lic Class � � � - . _� 3 9.9 A V
CoNractor.�/'�''�w` �7�S�n��e � � �� . . . , . �'• � • ° •a �
O
❑ 1 am ezempt under Sec. � � • •��2 5 � V
- Plan check fee t°
a
8.8P.C.(or this reasan' • • •5 a 2 5 u Z
PERMIT ISSUING FEE S C� `I�
Dore: 0 ri.0 7-$8
59nmvre TOTAL FEE
.- OWNER•BUILDER DECLARATION� PLAN CHECK APPL�CAM
I hereby offirm�hat I am eaempt from the Contracbr's Litense �� - �
Law for ihe foflawing reason(Seciion 7031.5,Business and NAME � � � � � .
Professions Code):--�-�--- -�� - � --
❑ I,as owner of ihe properfy, or my employees with /+D�RE55 �
- wages os�heir sole compensotion,wiil do�he work and-� CiTV
rhe 3truclvre is not intended or offered Tor sale(Seclion TEI.NO.
70E4,Buslness ond Pro(essions Code). � � py�NER
❑ I,as owner of the property,am exclusively contracting �IL
wiih licensed tonlrodors to consfrvtl Ihe project(Sec• ADDRE55 i�� y�e
�ion 7044,8usiness and Professions Code). �
CONSTRUCTION IENDING AGENCY �� GITY � �S iEL.NO. �'�'d U�
I hereby aifirm�hv��here is a constroction l ending ogency for ►
Ihe performance of 1he work for whtch this permit is iss�ed�- � GOMRACfOR - - -
(Set.3097,Civ.C.). . .
. _. _. .. _. __.. . . .. .
-- aooeess jJ�/�o �Q7 _ _ _
lender'e Name y�7 - - �� "� �� � --� � ---- ��
.. CITY . � . . .. TEL NO.'/J(r' 7.� Ya ... .. .. . ...
lender's Address - - � - - �--
STATE ��^ l/ �1�_ /' �7;�
I certify�hal I have reod this applicolion and slate�hal the LiCENSE NO.� a�7 CIn55-�L✓
. , ..... ,.'--.. ._..-_.. ----�---
...._. . _...._._
a ove information is correct.I agree�o tomply with oll Counry - '--� '
ordinances and$toie laws relating to building conshutfion,. � "
ood hereby aulhorize representatives of this CouNy to enter -'�� � �- � � � � � � -��� �- --�-- ��------� -- - - � . .
opon the above-menrioned properry for i specfi n pur oses. SEE REVERSE FOR EXPIANATORY LANGUAGE .
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