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 . . . .. __._ ... _ . .. ._ . _ . . . .. .._ . . . _
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