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HomeMy WebLinkAbout1426A (8) �ti'ORKLRS'CO)1PENSATION DECLARATION 7GA364C A Pi'L ICAT I O M1l�'FO R P E R i��11T� . . , � � CE.818 12�801 � . �1 herehy af(irm that 1 hacC a'crrtifica[e of c�nsent to self � inwre,ur a certifitate nf 1Vnrkrrs'Compensation fnsurance,oi � HEAT�NG-VENTILATING-AIR CONDITIONING . a certified cnpy thereof(Src.3800,Lab.CJ . Pn�icy No. Company COUNTY OF LOS ANGELES (iUILDING AND SAFE7Y � � Crrtified mpp is hercby furnishrJ. � - . - � � Cartifiel copy is Ciled�eith the munt��building inxpection � � FOR APPLICANT TO FILL IN OUILDING . �\ ���-��C"�- �� depar�menh . ADDRESS . Ki LS�1�� Date Applicun[ (PRINT OR 7VPE ONLVI ���'�;� LOCALITY \ \ NO, TVPE OF APPLIANCE OR EnUIPMENT FEE �_t�� CIiRTII'ICATL OF EXE\1FtTION PRO�7 N'ORKERS' NEARFST 'I�` � } CO�iPLNSATION.INSURANCti CRO55 ST. ` 1 n- (7�115 52Cfi(In nCcd nOt hC C0111P�C[ct1 1([fIC ��rork InY01vC[j A850RPTION UNIT,6TU � .- 0 by tlie permil it fm one hundred dollars (5100)or IestJ o��sTa��cT r�o. '�v��cesseo v V f cerfify ih�[in ihe performance nf ihe���ork fnr u�hich-thic AIR HANDL�NG UNIT,CFM - � � _ permif is issued,1 Shall nnt empluy any pers�n in nny manncr - �` _ \(�l0f�1 L� ��� � - so�s m hrc mr ubject to the��' rkers'Comprnc ir 9 CB�vs. BOILEF,HTU __ �`i'� pFPROVAIS OATE - iNSPECTOn'SS�GNATVRE U � �/-� /� n I W \ �)ata_��y�DL'Iican�.H�.`-�.._�/_��,yJ,� COM1IPRESSOR,BTU ROUGH z / �f- //��� I vNUTICF.TO�YPLiGtNT:If,�Icr maki//�his Certific�Y:�f VENTILATION SYSTEht- FINAt, - I'<rmption, ynu should become subj��[ tn Ihe t5'orkers' (:ompens:�li�n ptnt�isinnc o(tho LShor Cn�e,y0u mu<t f��tth- � ���npCqnr��,�E CDOLEP. � VALIDATiON :rith eo^p!� �.ci:h suah yrnvi;iont ur LLis prrmit shstl be deemeJ revoked. � . FURNaCE: FAU_GRAV�TV . LICENSF:D CONTftACT�JRS DFiCLARA7'[ON FLOOR' BTU . i herchy affirm that 1:im licensed under�+�n�'ici�ns�tChaD�er HEATEF7: SUSPENOED UNIT 9 (c�nimencing with Seclii�n 7000)af 1)i�'ision 3 of th��f3iisi� WALL nrss anJ Prnfessinns Code.and my litense ix in fuil forcc and effect. - ' �-.. O� Licrnse Number Lic Class �D . Contractor D�te . . . 1 ��� � � I am exempt frnm the Iicensins requirements as I am a - � � 1 licensed arthitect or a rtS�s[ered prnfessional ������rr��_ Plan cheek fee 25`.'-o Of dbOv6. scting in my pmtrssion�l capacity (Sectinn 705t. IIus- pERMIT ISSUING FEE S \ � � I • 'rness and Professions Code). \� Lic.or Iteg.No. D�te � TOTAL FEE ��� � � 110\760\1'V1�:IL-i3U1LDFR DECI.AR.4710N PLf1N CHECK APPI CANT /� � g 1 4 2 6 A ! hereby affirm th�t I am e<empl frum-the Contractor's fdAPdE/ � Id. /�(/��� _ �� #�• •�,• • •$ License .,aw fM[he foliow'inF reacon (Sectinn '7031.i, Busi- �•- �J t� - nrss' d Profe«innc Code): AOD�7ES5 _O6~S% �� _c�F�Nt'1— I � 2 Q 5 0 . . � I, as �����nrr of[he property,�vill dn thc«•ork and the C�TY TEL.NO�/y�6��'�i� � '�, _ stnic tu[e is nat intended �r o(ftred f�r 3�Ie (Secti��n ��r] _ _ •{ •••�•2 Q 5�� 7016,[3usiness and Ntnfessf�ns C�de). 06YNER/ 7.'� �_ � 1,as n���nrr nf tl�e property,am exdu5ively conir�ctinc �'��C � ��� .�2�'7-$4 �J �vi�h IicenseJ cantrnctors 1� ��ns[Nc( the project h7AIL `� �� (Sectian 703a,[lusineu an1 Pmfessionc Cbde). ' ADORESS /�y.N_� - f� �l � CONSTRUCTION LENUING AGLNCY �� CITY TEL.NO. �� I I hereb5' �«����� �Lal tberr is �consVUCtion Irnding sgenty . i � � . CONTFiACTOR �l r (or the performance nf the��vork fm ichich this F+zrmit i5 � 'sued(Sec.3097,Ci�'.CJ. � . - Lznder's Nsme � nDDRESS + Lcnder's Addrtss . CITY TEL.NO. I � l certify [hat 1 have rrad this:,rru��uon and state that ihe STATE LIC. ' above inFormation ic rnrrrct.1 a�ree to compl5'ofth all CuunTy UCENSE NO. CLA55. . � � ordinsncre snd State Inas reguia[ing Iltating,VentilatinK`.�nd � � Air Conditiuninc,�nd hereby auth<vize reprrcent�tives of thia SGG RfYI:RSIS I�UR fXPI.ANATOItY LANGUAGfi _ . - County tu enter upnn the a oee-mentinned proper�y for i .nn purpn�va. � ����--�T ..��-�'_��' � 1—a�_ndture ntt' tce � Jate / \ . � . . . . � • �, �, : N ' - . y` ^ � -. . �O , - . � . � ., � . � 9 - - , N Z • O _ N .� i � ' � v'o , " m . , n� ��` . � N --, �_'r . � ' l ' N •r• • ,1' . �1 ' �� l.� , . _I . / , I ! ` ' \ . t..J�" ♦ , � , . . .pr�r Ci 1� . � �' ' � _ 'F ' - �I .. C' :. 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