HomeMy WebLinkAbout1387A (7) WORKERr�oMPENSAT�oNOE«AaAT�oN � � APPLICATION FpR PERMIT� � �
I hereby�aFFirm thot I have a certificafe of consent to self -
insure,or o certifica+e of Workers'Compensation i�5��o��a, HEATING - VENi1LATING - AIR CONDITIONING
or a cerBf'ed copy thereof(Sec.38 ab.C.) � � �6A364� . .
CE•818(REV,10/Bl) �
� Polity , �� � ompan 1 . � . . , . . �
� Ceriified copy�s hereby Furnishe . COUNTY OF LOS ANGELE$ - BUILDING AND SAFETY
�� CeriHted copy is(iled with the county building inspeo FOR APPLICANT TO FILL IN BuitoiNG
ADORESS � ��
� fiondepartme t. (PRIMORTYPEONLYI . �� � � �
Dote � 'Applimnt NO. TYPE OF APPIIANCE OR EQUIPMENT . . FEE t�LITM
CERTIfICATE OF EXEMPTION FROM WORKERS' NEAREST � /J
�� COMPENSATION INSl1RANCE � � CQO555T. �/'' /—
(Thi��ecflon naad nof bo complNrd if fhe work involvod by . ABSORMION UNIT,BTU DiSTRI�T NO. PROCESSED BY
fhi parmlt ts for one hundred dollars(SI00)or lese.) qIR HANDLING UNIT,CFM ` �(y� \
I ceriify ihof in�the performance of 1he work for which ihis . 1 0 � �\Gt\C,d`�
permif is issued,I sholl nof employ any person in any manner - gO1lER,BTU �
— so os to become svbject to ihe Workers'Compensation LawS. nPPaOVniS onh INSPECTOR'S S�GNATURE'
� COMPRESSOR,BTLI ���� I� OUGH ..Z� �
Oata applicant - - .
NOTICE TO APPLICANT: If, after making this Certifimte of VEN11lATION SYSTEM . FINAL �+
� Exemp�ion, you should become subject ro�the Workers'
Compensation provisions of 1he Lobor Code,you musf forlh- EyAPORATIVE COO:ER VALIUATION
- with comply with svch provisions or this permit shall be - . . .
deemed revoked. � -� - FURNACE: FAU__GR VITY /
� � - . LICENSED CONTRACTORS DECLARATION FLOOR BN (� .
�I hereby affirm fhot I am licensed under provisions of Chapler 9 HEATER: SUSPENDED UNIT_ - ' .
��(commencing wi�h$etlian 7000)af Division 3 of the Bosiness �''A« . }
ond ProfesSions Code,ond my license is in fuU foice and effed: - . �� ����+ � O
, �Licensa Number Lic CIas3"r `�-' - "� -- , -`�°� 3�'7 p U
�, a
. Contm[to Dafe �� v . . �• e . • •fj v
❑ I am exempt under Sec. . . -_ _ . � 4 'S 3 2 5 �++
Plan check fee a
B.BP.C.for this reasorc PERMIT ISSUING FEE S C' � � �J�'2�` �
Dote:
TOTALFEE 09,07-88
Signoture
OWNER-BUIIDERDECLARATION �� MANCHECKAPPLICANT �
I here6yaffirm Ihat I am exempt from ihe Coniractor's litense � �
law for the following�eoson(Sec�ion 7031.5,Business and NAME
Professions CodeJ: � � �� �- �
❑ I, as owner of 1he propery, or my employees with ADDRESS ' . � �
-- - � wog05 05 fheir sole compensofiOn,wlll c!o ihe work and CITY - TEL.NO. �
the slructure is not intended or o(fered for sole�Section , .
7044,Bosness ond Professions Code). � � OWNER �
❑ I,as owner of the p�operty,am exdusively confmcting,_ �t _ _.._ _
with licensed contractors to construct the projed�Sec• qDDae55 / /l
� tion I044,8uiiness and Professions CodeJ.
CONSTRUCTION LENDING AGENCY -� pry� � - � � TE NO. ���� -
I hereby affirm ihot Ihere is a tonstructlon lending agency far
the performance of the work fot whlch�his permit is issoed- CONTRACTOR- � � � �- - ►
(Sec.3097,Ctv.C.). . � . . _.. .--- -.. ._.. . _.
nooaess . _ _ '
.. . . i�. . . . ---
lender's Nome � �/� •
� r � . . CIN � TEL NO.' �Y � __.. _ _ _. _ _ . . . . .
Lender's Address
STATE , /� (� IIC. ..�
I certify that I have read fhis applimtion and state thal the LI[ENSE NO. �-L ( �-C1A55 -� ------- �- -�- - - �� -- - � - �-�- - �
above in(ormotion is cortec�.I ag�ee�o tomply with all County
ordinances and State laws relating�o buildinq tonstrucfian,_._� . .. . . ... ,
ond hereby aolhorize representatives oi Ihis Covnty lo enter . , � �
upon ihe abo�e-mentio`d properry for inspection purpos s. SEE REVERSE FOR EXPLANATORY LANGUAGE. �
_
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norure af A imnt or Agenr Date � � . . . .. ... .. - . . ...... ... ..... .... . . . ... .
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