HomeMy WebLinkAbout1386A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT� �
I he�eby�offhm thot I have a certifimte of consent to self � �
insore,or a certilitate of Wo�kers'Compensation Insurance, .— HEATING - VENTILATING - AIR CONDITIONING L�
or a certifi d to y thereof Set.3800,Lob.C.)� � �6/+36eC ,
n CE-818(REV.10/81)-
_ . _ ._.... . __. .
p❑oiicy N 1 L mpony . . . _ ... . . _ .
Certifled copy�s hereby furntshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the munty building inspeo- FOR APPLICANT TO FILL IN qooaE559 � �/oY7� �
1tion de rlmenl. //� � (PRINi OR TYPE ONtY) . " ��� �' "'
Date �i I� ApplicaM r`✓ LOCALITr � �'z�`'� / �-
NO. NPE OF APPLIANCE OR E�UIPMENT FEE
� CERTIFICATE OF ExEMPTION FROM WORKERS' - NEAREST
� COMPENSATION INSURANCE � CRO55 5T. /' �4 '
(This eoetlon naad not be eomplatod(F fha work Involwd by . ABSORPTiON UNii,eTU ois�aia No. vaocesseo av ��
the permlt fs for one hundrad dollori(;100)or less.) qIR HANDLING UNIT,CFM /��
I certify Ihat in the performance of ihe work for which this , V '�{�0.`v y� 2- ',,
— permit is issued,I shall not employ ony person fn ony manner BOILER,BTU
� so as to become subjett to the Wakers'Compensation Lav+s.. nPvaovats onr[ WSPECTOR'S SIGNANRE
Da�e� � ApplicaM � COMPRESSOR,8TU � "✓ ROUGH -2 ��—
NOTICE.TO APPLICANT: If, ofter making this Certificate of veNmnnoNSrStenn FlNAt Z � [f�
'-Exemption, yoo should become subjed to�the-Workers' � '
Compensalion provisions of 1he La6or Code,�yoo�musf fodh- � EyqppRqT�VECOOIER VALIDATION
with comply with s�ch provisions or this permit shall be
deemedrevoked. . � -� � � � � '- -� FURNACE: FAU_GR VILY - � � ����
� UCENSED CONTRACTORS DECLARATION- FtOOR � siU �J �
� � I hereby aHirm ihat I am licensed under provisions of Chapter 9 HEAhR: SUSPENDED UNIT_ -
.'(tommencing with Sectian 7000)of Divislon 3 of fhe Business WA« ,
ond Professionz Cade,and my license is in full farce and effecL � � - �� -�" �" � ' _ d
L(yK.��j�l C-Z�I �.- o
.License Nombe� Lia Class � - , � � - , V
T�:2J ffr5� /l- �� _ =� 3 a b a ,�
Controttor, te #$. . . e .g O
❑ I am exempl under Sec: - � _ �v� v
Plan check fee I • a 2 5 a
N
B.BP.C:for�his reason PERMIT ISSUING FEE S � .� � • a 5 3.2 5� �
Date:
5gnotu�e TOTAL FEE Z 0 9.0 7—8 8
� OWNER-BUILDER DECLARATION - PtAN CHECK APP�IGANT , . � �
I here6y offirm Ihol I am exempt lrom�he Contrador's License . �
Law for the following reason(Section 7031�.5, Businesi and NAME � � .
Professions CodeJ: � ' - � - -
❑ I, as owner of the property, or my employees with ADDRESS - �
�wages as their zole compensa�ion,wiil do the work and�-
Ihe str�cfure is no1 infended or offered for sale(Section Cltt TEt.NO.
-7044,Business and Professions Code). . �- � M - - - - -
OWNER �6
❑ 1,as owner of the property,am exclusively coniracfing
with licensed tontrottors ro mnstrucl the project(Seo- �"�� �- ��
tion 7044,Business and Professions Code). . ADDRESS
CONSTRUCTION IENDING AGENCY � - Giiv � � iei tv0. �� � �
I here6y affi�m that ihere is a mnstrucrion Iending agency for '
the per(ormance of the work for which Ihis permit is issued - CONTRACTOR - -- �-- � �
(Sec.3097,Civ.C.). � � . _ ...-_. . . . _ _.. � .
� . A�DRE55 . . . . . ' . . . . . . ..
Lender's Nome '
an _ m� Tei.No. � "T�� . _ _
Lender's Address �
STATE ( L LIC. /�
I cerlify fhal I have read lhis opplication and slate that iha UCENSE NO. —/ � CLA55 l.i� � �. . . . . _. . .. .
above information is coved.I agree ro mmply with all Covnty . .
ordinonces and State laws relating to building tonstruction, , � _, . _ , .
.. . . _ ._... .. --.. ..--- .. .. . . .
and hereby authorize representatives of�his County to enter � � _ ��� �- - - �-��� �
upo he o ve-me tioned property io��nspection pur osev � � �� �
Q � � SEE REVERSE FOR EXPLANATORY LANGUAGE _
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ISignatura o Applimnf ar Agenl Oate - . .� . - . .. ... .. _. -. ..
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