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HomeMy WebLinkAbout1411A WORKERS'COMPENSATION DECLARATION � � I hereby offirm that 1 have a certificate of consent fo 5e�f �- . APPLICATION FOR PERMIT ' insare,or a certifimie of Workers'Compensatton Insurance, 76A36ec HEATING= VENTILATING - AIR CONDITIONING or o certiFied copy thereof(Set.3800 ob.C.)� , _)�/� �^ CE-91&(REV,la/Bi)� .P❑ol-icy�T,C.V,��'`/�ompony. / , . _ . .. .: _ . Certtfied copy is hereby lumishe . COUNTY OF LOS ANGELES BUILDING AND SAFE7Y �� Cerrified copy is filed wi�h the touny building in:peo FOR APPLICAN7 70 F1IL IN eVn�iNG , f �� ��' � tion depor me 1. ,r�•f �� ��AI (PRIM OR TYPE ONLY) ADORESS . Dole /��Applicant-✓+'��'�'lk/ � LOCAtItt "7� NO. TYPE OF APPLIANCE OR EOUIPMEM FEE ' - GERTIFICA7E OF EXEMPTION FROM WORKERS' NEAREST �y�9 COMPENSATION INSURANCE � CRO55 St, �� � (Thft sac}ton n�ed no1 bo complMod iF the work Involved 6y- - ABSORPTION UNIT,BTU DISIRiCI NO. PROCE55ED BY the permit ts for ona hundred dollars(SI00)or Ies�.J . I certify thot in the performonce of the work for whitb this A�R HANDIING I1NIT.CFM� - �permit is issoed,1 sholl na�empby any penon in any manner 1 D �Q`b Y�'e so as to become subject to the Workeri Compensation Laws.„ BOILER,BTU APPROVAlS DATE INSYECTOR'S SIGNATURE ` Dote � npp���a�� COMPRESSOR,BiU ,D �' ROUGH 9..� CT,.�� NOTICE i0 APPLiCANT: tf, after moktng this Cerriiicate of vENtitATiON SVSTEM flrtAt ( �' �� Ezemption, you should become�svbject b��he�Warkeri � Compensofion pravisions o�ihe lobcr Code,you�,�sr fo.+h- Evaroa,anve eeoee� � VALIDATION with comply wilh such provisions o� fhis permit shall be • deemed revoked. FURNACf: FAU G A N - i� _� -� � LICENSED CONTRACTORS DECIARAT�ON� - fi00R BTU � � I hereby offirm�hof I om licensed under provisions of Chopler 9 HEA7ER: S�SPENDED UNIT_ � '(tommencing wiih Section 7000)of�ivislon 3 of the Bosiness WAtI and Pro(essions Code,and my�icense is in full forc and effec4 � } (f(�/(/`'�'' ( /J S a License Number `�y� . .Lic.'Clas r��- - . _. - , `.� 4 1 ' A 0 , Contractor '��'✓"���C/�Dare �� � � - � '�{. . o e o 8 O � r I am exempt�nder Set. I e ��9�5 V W Plan check fee n, . 8.8P.C.for rhis reason� � y - PERMIT ISSUING FEE s (� • • �4 9.7 5� Z Dote: — Signoture TOTAL FEE 0 9,0 7—b 8 � OWNER•BUILDER DECLARATION 7lAN CHECK AFPLICANT � � I hereby afFirm that I am ezempt from the Controcbr's Litense _ ► I Law(or ihe folfowing�eoson(Sedion 7091.5,Bosiness and NANIE . . ' � _ � I Professions Code):� � j ❑ I, as owner of fhe property, or my employees wilh ADDRESS - wages os their sole mmpensa�ion,will do the work ond � �he structure is not infended or offered for sale(Settion ��� TEL.NO. � 704-0,BuSiness and Professions Code). _ - - . OWNER ❑ I,os owner of the property,am exclusively contraUing - with litensed mntrodors�o construet ihe projetl(Seo- ��� /1�.�� - fion 7044,Business vnd Professions Code). � ADDRESS �/� f9vL CONSTRUCTION LENDING AGENCY - �Ry- - � � ��;NO.��.��� 1 hereby offirm thof there is a cons�ruction lending ogency for the performance of�he work for which this permit is issued l� /1 �Se[.3097,Civ.C.). � CONTRACTOR ' .cl/ � � �-" . __- - _ -- ADDRESS �j /�'+}.� �� �� �� ' Lenders Name- ` /h /Ip Ul • . .... .... . .. . .- . . . CITY . .TFI.NO. 7 .____ ,._. __ . . Lender's AddreSs � � J Q � - --— � - �--� -� .- STATE t' ���, I cerlify that I have�ead ihis application and state that rhe- LKENSE NO. K CLn55� -Lr�- -. - � . . __ __- --- - _._ . o6ove iniormotion is covect.I agree to comply with ail Counly . � � ��- � - -"----•- -- ordinances and S�ale laws relating lo building consrrucfion, � . ond hereby aothorize representatives of this CouMy to eNer � � '"''� �� ' --- - -- -� � � - � opo t e above-mer�loned properry{or inspenion purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE . � r� "� . _. .. .... ._.. __ ' _ Si nature of Applicont or Agent - Dota . .. . . . ... . . .. .... . ... ...... .-'-' -- . . .-. • � � ' '�t ;�+�` � . . ,- �, `\ i r � ,`� ti ' i 1 � . , _ • ; � ,, - � ; - `4 ' �� • 4 ..l �,�-.S • , . '� � � � ,+> . i�`, , . ��. . �,'. � . ��� 1 � , � . .1� =r,!� � l, :� �,, . i'� �tI `j� ' ` i_ ' - '�', \.,f 1 �l _: -�r � ' ' .�' � ` � \ , r ' ... j� ',r � i � e` �O � " ��� � ��,� .� ' o ` +, a: , ' �'.. ' � . �. � ,� . , . � - ,` -_�- - t� : . N ; . ' a . . . � . . .. � , \ � ' "� - ,' � - . .. 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