HomeMy WebLinkAbout1411A (7) WORKERS'COMPENSATION OECLARATION � �
I hereby offirm that 1 have a certificate of consent fo 5e�f �- . APPLICATION FOR PERMIT
' insore,or a certifimie of Workers'Compensatton Insurance, �6A36ec HEATING= VENTILATING - AIR CONDITIONING
or o certiFied copy thereof(Set.3800 ob.C.)♦ ,
_)�/� �-7 CE-81 e(REV.10/Bi)�
a�Y rbK-Y/�l�/�ompony. / _ _
Cerrfied copy is hereby lumishe . COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
�� Cerrified copy is filed wi�h the touny building in:peo FOR APPLICAN7 TO F1lL IN eVnQiNG , f �� ��'
� tion depor me 1. ,r�•f �� ��AI (PRIM OR TYPE ONLY) ADORESS .
Dole /��Applicant-✓W�'�'lt/ � LOCAtItt "7�
NO. TYPE OF APPLIANCE OR EOUIPMEM FEE '
- GERTIFICA7E OF EXEMPTION FROM WORKERS' NeneEST ��9
COMPENSATION INSURANCE , � CRO55 St. �
(Thk sac}ton n�ed no1 bo complMod iF tha work Involved 6y- - ABSORPTION UNIT,BTU DISIRiCI NO. PROCE55ED BY
the permit ts fer ona hundred dollars(SI00)or Ies�.J .
I certify thot in the performonce of the work for whitb this A�R HANDIING I1NIT.CFM�
- 1 D '(�0.����
�permit is iss�ed,1 sholl nat emp�ay any penon in any manner
so as to become subject to the Workeri Compensotion Laws.„ BOILER,BTU APPROVAlS DATE INSYECTOR'S SIGNATURE `
Dote � npp���a�� COMPRESSOR,BtU ,D �' ROUGH 9..� �`
�J
NOTICE i0 APPLiCANT: tf, after moktng this Certiiicate of vENTitATiON SVSTEM FlHAC ( �' `�
Ezemption, you should become�svbject b��he�Warkeri �
Compensofion pravisions o!ihe labcr Code,yoo must ferth- �qro�aiiv�eeoeEe ' VALIDATION
with comply wilh such provisions o� fhis permit shall be •
� deemed revoked. FURNACE: FAU G A N - i� _�
-� � LICENSED CONTRACTORS DECIARAT�ON� - fi00R BTU �
� I hereby offirm�hot I om lifensed under provisbns 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 `�� . 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,
, B.BP.C.for fhis reason� - � • • 0 4 9 7�U Z
- PERMIT ISSUING FEE S
Date: —
Signoture TOTAL FEE 0 9,0 7—b 8
� OWNER•BUILDER DECLARATION MAIJ CHECK AFRICANT � �
I hereby afFirm fhat I am ezempt from the Controcbr's Litense _ ►
I Law(or ihe folfowing�eoson(Sedion 70J1.5,Bosiness and NANIE . . ' � _ �
I Professions Code):� �
j ❑ I, as owner of fhe property, or my employees wilh ADD4E55
- wages os their sole mmpensa�ion,will do the work ond �
�he structure is not infended or offered for sale(Settion ��� TEL NO. �
704A,BuSiness and Professions Code). _ - - .
OWNER
❑ I,os owner of the p�operty,am exclusively contraUing
- with licensed mntrocrors�o construet the projetl(Seo- ��� /1�.�� -
fion 7044,Business vnd Professions Code). � ADDRESS �/� f9vL
CONSTRUCTION LENDING AGENCY - �Ry- - � � ��;NO.��.���
1 hereby offirm thot there is a mns�ruction lending ogency for
the performance of�he work for which this permit is issued l� /1
�Se[.3097,Civ.C.). � CONTRACTOR ' .cl/ � � �-"
. _ _. . . _.
' AD�RESS G /�'+}.� �� �� �� �
Lenders Name- < /✓J /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 Stale�aws relating lo buHding consrrucfion, � .
ond hereby aolhorize representatives of this CouMy to en�er � � '"''� �� ' --- - -- -� � � - - �
opo t e above-mer�loned properfy{or inspenion purp ses. SEE REVFRSE FOR EXPLANATORY LANGUAGE_
� r� "� . _. .. .... ._.. __ ' _
Si narure of Applimnt or Agent - �ota . .. . . . ... . . .. .... . ... ..-.. ----� -- . . .-.
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