HomeMy WebLinkAbout1388A (7) 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�� � - -
��/��A���J CE•818(REV.10/81 J- -�- �
Dcy O�� / ompanY�"i r� F�V 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 . - . . . . .. .. . ' . . . . —--'. _.. . ... . .. _ .._
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