HomeMy WebLinkAbout1385A -WORKERS'COMPENSATIONDECIARATIDN APPLICATION FOR PERMIT
1 hereby�aif'mm Ihol I have a certifitate of consent to self � � �
insure,or a certificate of Workers'Compensarton i�s��a��e, �aA��� -- - — HEATING - VENTILATING • AIR CONDITIONING 1�
or a2erti�fiqyd�pcopy thereo/i�(Sec.3800. .C.) . �E-ele(aEV.loial) .. . .� . . . . -... . �
�P❑olicyNb�c.-/�f�2 'fcUmpony . � . . � � .
Cernfied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified topy is filed with the coun�y 6ailding tnspec- . FOR APPLICANT TO FILL IN . eunoiNG /
tion depa�finent. ADORE55 � Ll�� ��
XG (PRINT OR TYPE ONLY)
- Do1e �/�V Appltmnt � NO. NPE OF APPLIANCE OR EQUIPMENT � FEE ��'�Irr ��
� . CERTIFICATE OF EXEMPTION FROM WORKERS'. - - NEAREST
COMPENSATION INSURANCE � � . Cz055 ST. � d- /"•
(Thls ssctlon nsed nof be complotad if}ha work Inrolvbd by � ABSORPTION UNIT,BTU DISTRICE NO. PROCESSEO BY
fha permit is tor ona hundred dollan(SI00)er les�.) �
I terfify thof�in the performance of ihe work for which this. A�R HANDLING UNIT,CFM� I � ��\Q n,�
permit is issued,I shall not employ any person in any manner � gpILER,BTU -
- so as fo 6ecome sobjed fo the Workers'Compensofion laws. _ / .nPvaovais DATE . MSPFQOR'S SIGNA7VRE
. I COMPRESSOR,BTU � LO � ROUGH p-Z� ���
Dote �APPlicant � � .
NOTICE TO APPLICANT: li, ofier moking this Certificate Of VENTI�P,TION SYSTEM FinlnL (./'�—�
� Exemplion, yo� should become subject to the Workeri
Compensation provisions ot Ihe la6or Code,you must forih- EVAPORATIVE COOLER VALIDATION
with comply with�svch provisions or this-permi�shall be �
�deemed revoked. � � ) FURNACE: � FAU—G AV /� �
. � LICENSED CONTRACTORS DECLARATION� � ( FLOOR BTU -
I hereby oi(irm fhot I am licensed under provisions of Chople�9 HEATER: SUSPFNDED UNIT—
���(tommenting wilh Secfion 7000)of Division 3 of ihe Bvsi�ess � ' wAtl
and Professions Code,and m7y license is in full forc/e ond effect. � 1 � . O
license Number ���`�� Lla Class`-' ��� .. .. . � .. ..- -. - ... ► � V
iZ �
. Conimctor � Date /✓ . .. .. . .. .. �� ,3 Q,,F,A . �
❑ I om exempt under Sec. . --.- - - - ' � � � y
Plcn check fee # '8 w
N
g.gP.C.for this reason PERMIT ISSUING FEE S .(' I • •5�2 5 �
Dote: TOTAL FEE ?iS + � a 5 3 2 S�
Signature
OWNER�6UILDER�ECLARATION PLAN CHECK APPIICANT . . �
I hereby affirm thot I am eaempt irom the Coniractor's License . �. 0 9 0 7—8 8
Law for the following reason($ecfion 7031.5,B�siness and NAME � � �
Professions Code): - -- -
ADDRE55
❑ I, os owner of 1he properly, or my employees with - - �
� wages as their sole compensotion,will do the work and ��T� _ h�,NO.. �
ihe slrudure is not inlended or offered for sale(Section
704d,Business ond Professio�s Code). OWNER � �
� ❑ I,as owner of the properfy,am exclusively mntrading �„ /1� _ _ �
with licensed conlro[fors to conslrucl the projecf(Sec- ADDRESS � /T//�
-- tion 7044,Bosiness and Professions Code). ,
CONSTRUCTION LENDING AGENCY CiTY TFt. O. i -
I hereby oifirm that the�e is a consfruction lending agency for ,
the performance af fhe work for which this permit is issued �ONTRACTOR �- - � � �- � � ' �
� ($ec.3097.Civ.C.]. . - r - ._. .. .. ..... _. . ... .. . . . .
' ADDRESS_. �-,�/� . .. . � _ . __ . . . ._ _ �
lender's Name �
� _ � CRY � �. TEL.NO. � . ' . ._ _._ .._ .... ..- - '_ _ .
_. _
lender's Address
STATE � I r'L!l /� LIC. .� %�
I certify that I hove reod fhis application a�d srme ihar rhe - - uceNSE NO. `'Y�!1(��(- ans5 �LC��� -� � �-� -- ---------� �-� �- -- � � �
above informalion is correct.I agree to comply wifh all Couny -
ordinances and Stote laws relating to bvilding construction, � . . . � __ _ . .- . . -.
_ _.. . .._ . . . . -- -�- -� - - _. . ...
and hereby aulhorize representalives of this County to enter � . ,
vpon e obov -mentloned property for inspection p r ses. SEE REVERSE FOR.EXPLANATORY LANGUAGE _ _
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� _ _ .. . ___
SignoNre oi Appliconl or Agenl Dme . ..- . . ._ .
_. . __
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