HomeMy WebLinkAbout1408A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � I hereby affkm that I hove a certificate of mnseni Io seli insure,or o certificn�e ot Workers'Compensation Ins�rante, HEATING - VENTILATING • AIR CONDITIONING or d cerfified copy ihereof(Sec.-3600 b.C.) � ���� � ' �. ' . . . _ _ .... n (� " CE-818(REV.10/81) P❑olicy N�j�r.�"�I�1�ompany . - . . . _ . Certified copy is hereby furni5hed. COUNTY OF LOS ANGELES BUILDING AND SAFETY �Certified copy is filed with the�county boilding inspeo- - - - FOR APPLICANT TO�FILL IN BUUDtNGn+} �7 fi0n deporimenL � (PRINT OR TYPE ONtY) ADDRESS( ( � ��'l � . Da�e��ApplitaM LOfALIN �-�7 � NO. TYPE OF APPIIANCE OR EQUIPMENT - FEE �ERTIFICATE OF EXEMPTION FROM WORKERS' � NEAREST n � COMPENSATION INSURANCE ' ' CROSS 5T � %��1�H (Thf�tacfion n��d noT bo tomplof�d IF Iho work Involvad by ABSORPTION UNIT,8TU OISIRICi NO. CROCESSEO BY 1ha perrtdl It►o�ona hundrod dollers(5100)or lass.) . q � I Certi{y 1ho1 in the performance of the work for which this AIR HANDIiNC'i UNIT,CFM ` � ��0. �,� .�, _ permit is issued,I sholl not employ ony-person In any manner _ so as to becoma s�bjecf ro the Workers'Compensafion Laws. , BO�IER,BTU APPROVAlS DAiE INSPECTOR'S SIGNATURE Date � Applitam COMPRESSOR,BTU v`r (V OUGH � NOTICE TO APPLICANT: If, af�er making this Certifimte of � vENiItATION SYSTEM F�N'4� Z (' �f1-- Ezemption, you sho�ld 6ecome subject to the Wo�keri Compensoiion provisions of the Labor Code,yoo most for+h- EyqppRqTiyE CpptEg VALIDATION with comply with such provisions or this permit shall be . deemedrevoked.- � �' � FURNACE: FAU_G, VI . � LtCENSED CONTRACTORS DECIARATION' cLooa e7U � I hereby aFfirm that I am licensed onder provisions of Chopter 9 HEATER: SUSPEN�ED - - UNIT_ - ��'(mmmencing with Secfion 7000)of Division 3 of the Business WALL r and Profenions Code,nnd my licensa is in full force and effect. � / . �,� 4 Q�F O //� _� _ License Num6er�o✓�Lic.Class `� �� - � . � " � � V �-, #�• : . . o�j 4' O controcror oare � � • •4 9.7 5 t�'i ❑ I am exempt vnder Sec. - . - � _ pW„ Plan check fee •4 9,7:i z � 8.8P.C.for this reason� � � 2 - PERMIT ISSUING FEE s � `� p p��_�� Date: TOTAL FEE Signatore OWNER-BUILDER OECIARATION PIAN CHECK APPLICANT , . I hereby affirm Ihat I am exempl from the Contracror's License , Lpw{o�1Me following reoson(Seclion 7031.5,8usiness and NAME Professions Codej: . � - - • ❑ I, as owner of the propery, or my employees with ADDRESS - � - � - wages as their sole tompensa�ion,will do tha work and � diY � TEL.NO. � � � the strudore is not in�ended or of(ered for sale(Section � � 7044,Business ond Professfons Code}� . � - OwNeR : � ❑ I,as owner of the property,am ezclusively conirading , �i� . ` _ w(th hcensed mntratlors to construct ihe project�Seo- qDDRE55 � tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY � -- Ci7y � � 7 t:ni0 � " � �hereby affirm thot there is a construttion lending agency for �� , fhe performance of the work for whith this permit iz issued �-� CONTRnROR � - - � �� -� (Sec.3097.Civ.C.). � � - -- ----_ . ." . - . . . . -. . � � ADDRESS /LL�� __.... . _ _. . . . .� . ... �� .. . . Lender's Name . CITY. r TEL.NO. 3(��S � ' . . . ..._ . __ . . . _ . _ Lender s Address STATE �/ r ' - UC. ^7 � � I certify�hal I hove read ihis opplication and state thof the LIGENSE NO. �-1 �Y CLaSS � � ��(_��� � � -� � - �--- - �- � - - - � --- - abave informa�ion is correct.I ogree to comply w'�th all Couny ordinances'and Stote laws relating to building mnsfruclion, � _ - _ _ . . . . . . . . . _. _ . .... .. ._ . .. ._. and hereby authorize representatives of.this CouMy to eMer � � � opon e obov -meCtione properry for Ins�on purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE G � ' - -- . .. . - , .. . . . .. .. . . ' -- - ... . _ . .. ___ .. . . .. ._ . ._._ . . . .._.. - SlgnaWre af plicaN or Age�� Date - � � _ , , - '� ti ` ''`;• . �\ ``,, ;" \,' '�,;� ,�'�,;','\ " ''" � . � `,� . � �� � . . 1� . , � . . �j}, .,�, • '` ., '� . . ..�. , ., . _ �,t., . • . . ' ' , 1 , , . � � . . . 't� . � . � ` � `,. � + � I .. �. 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