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HomeMy WebLinkAbout1388A WORKERS'COMPENSATIONDECLARATION ' APPLICATION FOR PERMIT � I hereby affkm thar I have a certifimta of consent lo self insure,or a certiticate of Workers'Compensation Insuronce, HEATING - VENTILATING • AIR CONDITIONING or a certified copy thereof(Sec.3600 lab.C.) � ��'�4�� � - - ��j���JCE•818(REV.10/81J- -�- � Dcy ��� / ompanY���/�I !/ILlJ�L - Certified topy is hereby f�rnished.� COUNTY OF LO$ANGELES . BUILDING AND SAFETY � CerriFied copy is filed wiih tha couny building Inspec- FOR APPLICANT TO FILL IN sui�DwG t14n dep rf ent. ADDRESS � /l'j , -. �� (PRINT OR TYPE ONLY) � �ocnun -Dole /�Applicanl�� � � �� NO. TVPE OF APPLIANCE OR EQUiPMENT FEE CERT�FICATE OF EXEMPTION FROM WORKERS' . -- NEnResi // � � COMPENSATION INSURANCE . CROSS ST. �f�l/ / / �(Thli s�ct�on nsed not be eomplaf�d if Ih�work involrad by- ABSORPi�ON UNIi�BTU O�SfRi�T NO.- PROCESSFD BY the permft is for one hundred dollars(SI00)o�lass.) � 1[erfify�h61 in fhe performanca of the work fm whith this AIR HANDLING UNIT,CFM D �Q\� permit is issved,I shall not employ any penon in any manner � — so as to become subjecf to fhe Workers'Compansa�ion Laws. gOILER,6TU APPROVAtS DAiE INSVEC70R'S SIGNAiIIRE De1e Applicant � COMPRESSOR,BTU v�� �Q OUGH �2�' �_ . NOTICE TO APPUCANT: If, after making�this Cerriflmta of VENi1tATION SYSiEM � FlNAI r i -Exemption, you should become su6ject �o the Workers' . Compensation provisions of Ihe Labor Code,you must forth• EVAPCRATIY:CCOIER VAUDATION � �- with comply with.soth provisions or this permit sha�l be � - - deemed revaked. - � � � fURNA�E: FAU- G i � . � LICENSED CONTRACTORS DECLARATION � � F100R BTU -� � � � - I hereby afiirm ihal I am licensed onder provisions of Chapler 9 HEAiER: SUSPENDED UNIT_ � - �(commencing with Set�ion 7000)of Division 3 of ihe Business WA« } and Professions Code,and my license is in full forte and effecf." � - y` �""� ,r�i� 0. /" ']� CJ r�� p License Num6er � Lic Class�- �-�' - -�--- . � - , � �� 3��4� V i� � Contrador f Dafe ��. . . . _ #• i o c e 8 0 H ❑ I am exempt under Sec. _ � � ���2 5 w Plan check fee N 8.8P.C.for this reason- PERMIT ISSUING FEE S � • �m 5�2 5� Z Dote: Signa�ure TOTAL FEE 0 9,0 7—b 8 � OWNER-BUILDER DECIARATION. PLAN CHECK AFPLICANT I here6y affirm that I am exempt from the Conhacior's license � low fm the following reason�Section 7031.5, Business and NAME � � Professions Code): - � - . ❑ I, as owner of the property, or my employees with /DDRE55 - �- wages os�heir sole compensation,will do the work and 1he siructure is not intended or ofiered for sale(Settion Cltt . TEt.NO. 7044,8usiness and Professions CodeJ. . � � � OVJNER /7. ❑ I,as owner of the propery,am exdusively contracting "�« wilh licensed conrraUors to mnstruct Ihe project(Sec• MA�� � � fi0n 7044;BVS�ne55 ond Professions Code). A�DRESS � - �ONSiRUCTION LENDING AGENCY - � � eiiv � �� et.No. �a�� � . �hereby affirm that there is a mns�roction lending ogency for . _ � the perfwmance of�he work for which this permif is issoed� - COrvTRnCtOa . �-- -� �� ���� (Sec.3097.Civ.C.). / /� �� . . . . . . . . ADDRE55 - CI C9�Y�AtQ . _ . .. ..--:.:.. .. .. . .... ... . _ lender's Name � . qTV ' TEL.N0. . � � .. . . . _._ _ . Lender's Address ��- STATE LIC. � . I certi(y thot I have read this npplica�ion and state�hal�he LiGENSE NO. �� � ���- CV+SS r � - --- � - - - above informa�ion is mrrect.I agree to tomply with all Counly � � ordinanres and$tate laws rebting fo building construUion, - . , and hereby aulhorize represen�o�ives of this CouMy to enter � - - �- �-- � - , � � - � ���- � " upon rhe abov -mepfioned properry f inspection purpo ez. SEE REVERSE FOR EXPLANATORY LANGUAGE ___ _ r�r Signo�ura o( pplimnt or Agenl Date . - . . . . .. .. . ' . . . . —--'. _.. . ... . .. _ .._ , �.�.--M� _.---.- '';� `` _ �, t �` '� + .. �.��i- ;i ,` ��,,: �- t � � � � - � � � , �� `� .. , �tt t '�: .. , . 1�c � .... �� � �� J, , , , M � � ' .. ,� .`\,' ,' .„1 , V 1 �1.. _ • � `. . . , �' � .,� . , . _ . - `(: t . � . . '', � ' � . . ' �e •�f • .., � , - � , . . i � .. . . c'. , . - .. � � �. .. � �, " - V� `. � ' ' � ' � � i . � \\ '1 1`\ �_; . ..,. 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