HomeMy WebLinkAbout1412A WORKERr�oMPENSAT�oNOE��ARAT�oN ;. �APPLICATION FOR PERMIT �
, �hereby'affkrrm thai I have a tertifimta of conseN fo selF
insure,or a certificate of Workeri Compensaron Insuronce, HEATING - VENTILATING - AIR CONDITIONING
or a certi(ed copy the eo (Sec.3800,� b.C.) , � ���� � � � �
, �'n �I�� �CE.8I8(REV.10/81) . . - � . � ' � .
�� P❑oli�cy��a� ompany , .. `. . .._ . . ..._
ertified copy is hereby furnished. COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
�Certified topy is filed w�th the counry building tnspec- FOR APPLICANT TO FILL IN BUIIDING� f`f
lion depar�lm'e/N. (PRINT OR TYPE ONLY) ADDRESS � �i� .
�� Date��/� V a �APPIimM� A��� LOCAIITY �Z
NO. TYPE OF AP7LIANCE OR EOUIPMEM - � fEE NEAREST /�
CERTIFICATE OF EXEMPTION FROAM1 WORKERS' - � CROSS Si. �L�Y � / /y(
COMPENSATION INSURANCE - ABSORFTION UNI7,B7U
,(This settlon naed no}be complated if fhe work Involved by DiSfRiCi NO. PaOCE55ED BY
�he permit Is for one hundrad dollars(f100)or leta.) y � � `
AIR HANDLING UNIT,CFM �
I certify thol in ihe performance of the work for which ihis-�-- , , � Q���(� � -
— pe�mit is issued,I shall not employ any person in any manner BOitER,BTU -
� so as to become subjeU to the Workers'Compensation Laws. ,_ naaRovnis onT[ MSPECfOR'S SIGNATURE
Date Applitant COMVRESSOR,BTU � C� ROUGH �6 C .
NOTICE-TO APPUCANT: If,-aRer making ihis Certificote of vENTitATiON SYSTEM FINAL .��� �'Q_� -
-Exemption, yoo should become subject to�the Workers' �
Compensotion provisions of the lcbor Code,you must forth- Eyqppttqirve cOOtER ' VALIDATION
� Wifh comply with such provisions or this permit shall be
deemed ravoked.- � � � �. � � � • � FURNACE: FAU_GRAV _- n
�� . LICENSED CONTRACTORS DECLARATION - FLOOR BTU (J '�
I hereby affirm that I am licensed onder provisions of Chopter 9 HEA�R, SVSPENDED UNIT_ -- -
'�(commendng wilh Seclion 7000)of Division 3 of the Business WAtI
and Professions Code,ond my license is in f�li force and effect. . / p�,
�n'� /1 rq �,$ ?141,2A o
License Number ����Lic.Class� W �- . . �" �- - " �� " � � V
� � , ,ym . . . aS O
Contrador � � Dote � • •4 4�7� V
❑ W
I am exempt under Sed PIa�CIt@CIC fBB ' • ^ •[�n, �`J� y
� B.BP.C.for fhis reoson� � �
2
PERMIT ISSUING FEE S ;O
�me: 09�07-88
TOTALfEE
Signat�re
OWNER-BUILDER DECLARATION� � PIAN CHECK APPlIC.4NT
I hereby affirm thot I om exempt from the Conhadar's License � -
Law for the following reason(Sedion 7031.5,B�stness�and NAME �
Professions Code): . - - � . .
� ❑ I, as owner of the properfy, or my employees with aDDRE55 � -
� wages as their sole mmpensaiion,will do the work and - � ��rv � TEL.NO.
the slrocWre is nat intended or ofiered for sale(SeUion � �
7044,B�siness and Prafessions Code). - �y�FR
❑ I,as owner of�he properfy,am eadusively mntracting �L ��.I- -
with licensed contractors to conslrocf ihe project(Ser AD�RE55 � � !�{�'
tion 7044,Bosiness and Professions Code). .
CONSTRUCTION IENDING AGENCY � : CITY � n'�S T L NO. i �
I hereby affirm that there is a cons�ruction lending agency for
the performpn[e of 1he work for which this permit is issued� - CONTRACTOR ( �- - � " � - � ►
(Sec.3097,Civ.C.). . . . .. .' .. .' .. .. . . .
ADDRE55 � �-� - � � -
Lender's Name �
. . . OTY_. � .. TEL NO. �L��(/�� ._ . __ _ . .
LendeisAddress - - .. �� .. ..�. � ... .. . -- �� -- �-
STA1E / ��L � LIC. /'_7\ � '
I certify that I have reod this opplitation and stale that the-- LICENSE NO.K � -- C1A55- �� �•��� �- -�
.. _.. .._ . ._. ... _. . _ .. .
above information is corred.I ogree to comply with all County , -
ordinances and State laws reloling to bvilding conslroction, _; _ . . '
and hereby aulhorize representatives of this Counly to en er . - �
up the ab�e-nfantioned properry for ins�jection pvrp es. SEE REVERSE fOR EXPLANATORY LANGUAGE
l /G� _
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