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HomeMy WebLinkAbout1384A (7) 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 ' . .. . . -'- ---- .. . ` - '�'� ' " . . _ .. . . . . . ... - --"'"-"' ,' r 4 ;� .,i� ' ' �=..,`- 1 `. \, `, . '� � ��,��_ A �: �,l'� . " ,� . ' '1, ',, • � �i � � �, � _._ . � ` ` , '' ' ,`i , � ' . , �,�,,' `' � ••�i ' • ,'i • � - �\ 1 x� ,�, � .� � , .•�! ' , � ' ' '� . � . .�l. �� , � . � �_ ��� ,� � /,i'•,� � ... 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