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HomeMy WebLinkAbout1400A WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PERMIT � � I hereby'pffirm tha�I have a ter�ificate of tonsenf fo self ��sure,or a ceriifitate of Workers'Compensmion Insurance.- - HEATING - VENTILATING - AIR CONDITIONING or a cerfi(ie m y ihereof(Sec.3800, b.C.) ♦ ��'�� � � - CE-B18�RFV.10/81) .. ��Y���P��Y _ . -- - -- --- --- � . Certif�ed copy is hereby fornished. COUNTY OF LOS ANGELES BUILDING AND SAFETY �Certified topy h filed with the tovmy bu�lding inspeo- FOR APPLICANT TO FILL 1N - - eU�LDiNG/��� A `��� 0�., � fion deparfine t (PRINT OR TYPE ONLY) ADDRESS�/ � f TC - Date ��Applicanl IOCALiTY .�� �� � . NO. ttPE Of APPLIANCE OR EQUIPMENT FFE . CERTIFICATE Of EXEMPTION FROM WORKERS� � NEAREST /!� L � �p;n' �- � COMPENSATION INSURANCE � � . CROSS 5T. [�/ �i/� (Thts s�ction nesd nol ba eomplN�d I(tha'work involvad by ABSORPTION UN�7,BTU �ISTRICT NO. PROCFSSE�BY �The parmit ia for one hundred dollan(fiDO)or lass.) AIR HANDIING UNIT,CFM �(�(� I certify that in Ihe performante of the work for which this� O \��L\`v'A`Q - � permit is iewed,I shell nol employ any person in ony manner � BOILER,BTU so as fo become sobject�o the Workers'Compensa�ion Laws._.. nvvaovais onr� INS�ECTOR'S S�GNATURF Date APPIi[anf COMPRESSOR.BN � �O v .� ROVGH Ir NOTICE TO APPLiCANT: If, after making �his Cerlificate o( VEMILATIONSYSTEM F�Na� j�'�C � - Exemption, you should became�su6jed to the Worke�s:. � 'Compensotion piovisions of the Labor Code,you mast forih- fiVAF02ATIVE COOLER VALIDATtON with�comply with svch pravisions or this permit shall be ' �deemedravoked. �� Fi�RGE: FAU B� G V V�`r /,^ � . � 'LICENSED CONTRACTORS DECLARATION �. �J �I hereby aHirm�hat I om�icensed onder provisions of Chapter 9� - HEAiER: SUSVENDED UNiT— -� �(tommencing wi�h Section 7000)of Division 3 of the Business ' WA�� and Professions Code,o d my liceose is in full fo te on�e1ec�. � � - � /� V /� �/J License Number �� Lia Classy���� . � � co�,�aao� � oma �' p'� , �14QOA � ❑ - • V I am exempl under Set. .�• • • •8 y Plan check fee ,� 8.8P.C.for this�eoson' pERM1T ISSUING FEE S � 1 • •��2 J� Z Date: TOTALFEE . e .�j��� Signat�re OWNER-BUILDER DECLARATION - � at/+N CHECK APPLI�nNT. . . . I hereby afFirm thot I om exempt from Ihe Contwctor's License- � 0 9.0 7—8 8 Law for the foliowing reason(SeUion 7031.5, Business and NnME � Professions Code): � �. � " ADDRE55 ❑ I, az owner of ihe property, or my employees with _ � wages as their sole compensa�ion,wi�l do the work and ��T� � iEl.NO. - the stroclure is not inrended or ofiered for sale(Section � 7044,Bosiness ond Pro(essions Code). . � � � � "�--�-� � OWNER ❑ I,ps owner of the property,am exclusively con}ratting �� , wi�h licensed contractors lo construct the project(Sec- qDDRE55 � r� tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY pTy fG� Et.NO.��i�(w J"� � I hereby oif'�rm that there Is a construction lending aganty for the performance of rhe work for which this permil is issued- � COMRACTOR �� �- � - ' . (Sec.3097,Civ.C.). . -.— ----. ._.._ .. __. . ... ._._..--� . _. _ . . .. .. ._ .. . _ . A�DRESS .. � .. � I7lQfCF..��_.. _.._. . . . ...._ . �.� �.. . .. Lender's Name � . . . CIN . � TEL.NO. � ._. . _ . . . ._ _ . . . .. Lender's Address STATE 1 I � LIC. _� I certify that I have iead this application and sta�e that Iha LICENSE NO. v�. � CLASS - ��--- - � -�� � � �� --- - � -� - �- � obove information is coriect.I a9ree lo comply with oll County � � ordinances and Slale lows relating�o building construction, _ . - _ ._ _ . __ . . . .. . . ..._.. _ ond here6y aothorize represenfalives of this Counly to enler � � upo e above-meyioned propert�r�nspecti��oses. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ ISi ioture o pplimm or Agen� J���re . . . .. __._ ... _ . .. ._ . _ . . . .. .._ . . . _ .-- " G���� ��� . _1" }, � `` i r� � �, E � � , ���i �. `' ' . --,- � ; ,, !r` ,i ,, . , ���� ���� ��' � �� ,� ������ ` - -- t� � � . `, . - .� ' ..t , i F .. �� - � �:�,�, ' ,;r . . �' , , ',, , ` . .r�'O `�d- � . �. t . ;y , ._i�� �'�_ � �- � • � � �� _ o , � � � � � . N �� f -� Z � , , , . . - �'n , ,\ - ' " .... . ���� , —�_ ., , � . � ;.. ;. �;� � ,� � � : _� � �� . � . 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