HomeMy WebLinkAbout1408A (7) 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 fodh- 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 � � . . . ..._ � ._ .
7 __ . . _
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
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