HomeMy WebLinkAbout1384A WORKERS'COMPENSATION DECLARATION � �
I hereby offirm thal I have a certificate of�o�=e���o-�e�f . APPLICATION -FOR PERMIT
tnsore,or o cerr�ficete of Workers'Compensmion Insvrance,-. .
oi a cernried copy�he�eof(sec:se , b.C.)� ian3eac ' ` " HEATING - VENTILATING - AIR CONDITIONING
��CE-818(REV.10/81) �
._ . . ..... _ _
❑cY m�� '; . . .. . ., ... . .
Certified copy is hereby fumished. �-COUNTY OF LOS ANGELES-. BUILDING AND SAFETY
�CerHfied copy is filed with tha county building inspec- FOR APPUCANT TO FILL IN Bui�DwG �/ ,
1 on deporfine L . ADDRESS � Sd'�
(PRINT OR TYPE ONLV)
'�- Dafe '�� �Appliconl � NO. TYPE OF APPUANCE OR EOUIPMENT FEE ���ITV 1-I �'7 C .
-tsi" LaJ
CERTIFICATE OF EXEMPTION FROM WORKERS' � - NeaeEST �
� COMPENSATION INSURANCE� � GROSS SL J-- lq �
� (Thts sacfion nood nof ba eompl�l�d i(1ha work fnvolvad by ABSORMION UNIT,BN DISTRICT NO. FRp�ESSE�BY
the psrmlf Is for onc hundrad dollars(5100)or lass.) � �
AIR HANDLING UNIT,CFM
1 cerfify�hat in the performance of the work for which this� � � �0.`O(� `� �
pe�mil is issued,I sholl nof employ ony person in any monner �
— �so as to bemme subjed to�he WoFkers'Compensalion Laws. 001LER,BTU APPROVALS DA1E INSiECTOR"S SIGNAiURE —
DUte - � APPIkaM COM7RESSOR,BTU � (Lr(,L�`� /O �� ROUGH /��� (�'�—
NOTICE TO APPLICANT: If, after moking �his Certificate of � VENTILATION SYSTEM FINAL � � C� —
Exemption, you should become subjett to ihe�Workers'
Compensation provisions of�he Labor Code,yOV mu3�fOrtfl- EVAPORATIVE COOLER VALIDATION
- with comply with soth provisions�or this permit shall be �
� deemedrevOked. � � - � FURNACE: .FAU—GRAVTY � /;y
� LICENSED CONTRACTORS DECLARATION-�.. FIOOR BTU V
I hereby affirm that I om licensed ander provisions of Chopter 9 SUSeeNOEo UNiT_ ' � '
HEATER: WA��
'(tommencing with Section 7D00)of Divisian 3 of the Business
and Professfons Code,and my license is in full farce and eHed: -- -�- �- � � 4
� . License Num6er Lic:Closs v � - - - - � - � , . �
� [ V
Conrracror ` Date � v� �1 3 8 4 A O
- ❑ 1 am exempt onder Set. �• � • • •a w
PI6n check fee a
0.8P.C.for thirreason PERMIT ISSUING FEE s c� � � ��J'�� �
Dote:
Signalure _ � T�TAL FEE Z ° ' 'Jr J',c�....�i=
OWNER-Bl11LDER DECLARATION . PLAN CHECK APPI�CANT � O 9�O 7—H 8
I hereby affirm that I nm exempt from ihe Contractor's license ,
Law for�he following reason(Sedion 7031.5,Business and NAN1E � . �
Professions Code): � � � �� �
❑ 1, as owner af the property, or my employees with AD�RE55 .
wages as their sole campenso�ion,will do the work and ��n, TEL.NO.
�the structure is not intended or offered for sole(Sedion
7044,Business and Proiessions Code�. . . � -� - �
OWNER Q
❑ I,as owner of Ihe properly,om exdu5ively tontmding -
with licensed contracrors to tonsrruct the projett(Seo- �`�� � -
�- �fion 7044,6usiness and Pro{essions Code). - ADDRESS �
CONSTRUCTION LEN�ING AGENCY. - CiTv � � �'�TEL: O� �v J�
� I hereby a(firm ihat there is a constr�ction lending agency for
ihe performante of Ihe work for which this permit is issued �pNTRACTOR "� -�- , .
(Sec.3097.Civ.C.). . ... . . . . .
. . . . . . AD�RESS � - �.l�. . . • .. � . -,_ .. _ . ..
Lender s Name /
�
. _ _ CIN_ TEL NO.���� _..
Lender's Address ' - - � � - - ' � �
$TATE LIC.
I ceriify�hat I have read ihis oppiication and state thm the �- uCENSE NO. c�n55 ��2�� �- --.. . . _. .._.. ._ . _
above information is correU,I agree m tomply with all Counry �� '�- ' .
ordinances and$tate lows�elating to building tonstrucfion,
and hereby authorize Lepresematives of this County to emer � - � - .� �� � � . �� � � " "�" -� - �� --" - - - - '"� � -
upo �e abov -mentiol�ed property for inspeclion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE _
-
���� _ . . - - _. . . . ._ _ . . . . _ . ..
G
S�gnorure of Applicanl or Agenl . - � Date ' . .. . . -'- ---- .. . ` - '�'� ' " . . _ .. . . . . . ... - --"'"-"'
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