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HomeMy WebLinkAbout1399A (7) 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 CE-818(REV.10/BI) O�l' � � ompany / . _ . Cer+ified copy is hereby furntshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY �p�9��/Certi{�ed copy is filed with ih`c'unty building��sPeo- FOR APPlICANT TO FILL IN euuoiNc (� ����ry ��, /—� tion depar merlt. ADORESS Date �a - Appli[ant � . . (PRIM OR 7VPE ONLY� LOCAIItt /f��J cJ/ � NO. TYPE OF APPtIANCE OR EQUIPMENT � � FEE " '" � . CERTIFICATE OF EXEMPTION FROM WORKERS' NEneEST /1 COMPENSATION INSURANCE- ' � � CROSS Si. /j,(�4� f—j�J!r _ (Thi�t�eflen n��d not 6o eomplaiad ti}h�work Involvad by - �+BSORPTION UNIT,BTU � mSraiC�tio. veoCeSs[o av }he permtf(s(or ona hondred dollars(SI00)or les�.) AIR HANDLING UNIT,CFM . ) /'� � � I certify Ihal in ihe performance of the wwk(or which this ��� a �� � permil Is issued,I sha(1 nol employ any peison in ony manner 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 APPUCANT: If, afler moking this Cenificate of VENT�L4TION SYSiEM � FlNAL � Exemption, you should become subjec� �o the Workers' � Compen5o�ion piovisions of Ihe[obor Code,you mus7 for�h- EyAppapTiV��pp�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 Ihof I om licrnsed vnder provisions of Cbapter 4 SUSVENDED 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 �- license Number 7�) Y3�� Lic Class � � � - . _� 3 9.9 A V ..CoNroctor.�'v✓`^'�iw` �7iY n��e � i �� . , . $''. � . ° .a K Q ❑ 1 am ezempt under Sec. � � • •��2 5 � V - Plan check fee t° a 8.8P.C.(or this reason' • • •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 APPLKAM I hereby affirm�hat I am e.empt from the Contracbr's Litense �� - � Law for ihe foflawing reason(Seciion 7031.5,Business and NANE � � � � � . Professions Code):---�---- -�� - � -- ❑ I,a:owner of ihe properfy, or my employees with /+D�RE55 � - wages os�heir sole compensotion,wiil do the work and-� ��TV the strudvre is not intended or offered tor sale(SeUion TEI.NO. 70E4,Business ond Pro(essions Code). � - py�NER ❑ I,as owner of the property,am exclusively contracting �IL wiih licensed tonlrodors to consfrvtl Ihe project(Sec• ADDRESS i/�� y�e tion 70d4,8usiness and Professions Code). � CONSTRUCTION IENDING AGENCY �� GITY � �S iEL.NO. �'�'d U� I hereby oifirm�hat rhere is a construttion lending agency for ► Ihe performance of 1he work for whtch this permit is iss�ed�- � GOMRACfOR � - - (Set.3097,Civ.C.). - . _ _. .. _. __.. ._ .. . ._ aooeess jJ`1�o � _ • lender'e Name y�7 � � � � - �� "� �� � --� � ---- �� .. CITY . � . . .. TEL NO.'/J(r' 7.� Ya ... .. .. . ... lender's Address - - � - - �-- STATE �/^ '/ p�, /' �7;� I certify�hal I have reod this applicolion and slate�hal the LiCENSE NO.� a�7' CIn55-�L✓ . , ..... ,.'--.. ._..-_.. ----�--- ...._. . _...._._ a ove informafion is correct.I agree fo tomply with oll Counry - '--� ' ordinances and Sb�e laws relating to building conshutfion,. � " ood hereby aulhorize representatives of this CouNy to enter -'�� � �- � � � � � -��� �- --�-- ��------� -- �. . . opon the above-menrioned properry for i specti n pur oses. SEE REVERSE FOR EXPIANATORY LANGUAGE . gnolure of App�or Ageni ��afe : . .. _ . .. . . .._ . _ . . .. .._. .. . .. ... . .... . . . . .. .. .. . .. 4 S , _ ' � '� 1 i . _ --'`� ,� +� �1 . . ',,� ��, !- . t' �r' .f/.,,� �y. i� �!, ,`,,�' ,~t I, '°�' ''• l • �1 1 ' ��' ....... j; , ,i �` �e '_ ' �'� 1�� �� � �� ' / �..' • .. �. � ' � ,' '`a/ ' ''��. ., , �� , 1`� o- . ' '\`� `.. !+� ' ' `,) lI r._.��. ZL .. .. .,`' , !S���t . ',.` . ' . . Z . - . 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