HomeMy WebLinkAbout1150A \VORKERS'COh"•PENSATIONDECLARATION � qpp��CATION FOR PERMIT � 1
I hereby�ffirm Ihat I hovc a ce.rlificotr. of consrnt to SRII
insure,or a cenificair.af Vlnrkr.rs'Co p�nsaiion Ins�ro�ce, �6A35eC ��� HEATING - VENTILATING - AIR CONDITIONING
or a cerfi ,c • ((Sac.3900 �b. ) CE-919(REV.IOi01)
Policy 1 ompony /'•
�Ceriifie cepy�s hereby fu�.... . /' f , COUNTY OF LOS ANGELES � BUILDING AND SAFETY.
Cerufin copy is iiled wirh ihe ounry b�ilding'ns c- FOR APPLICANT TO FILL IN oui�oiN — /
� n me (PRIYi O�TYFE ONLY) �D�RE�
/ i
001� pplicant �� LOCALITY
O. TYFE OF AP�LIA!.�CE O4 EQUIP.4�ENT FFE
CERTIFICATE OF EXE7.tPTION FR .n WORKERS' NEncEST
CO•'+tPENSATION INSURANCE CROSS ST.
(Thts sscNen noad nof be tompleted if iha work fnvolved by A65C�7PTICN U.'JIT,BTU DiSIRKI NO � Pxp�ES'FD 9Y
Ihe permil t�lor one hundred dollars(5100)or le��.) ` �
AIR HAN�LING 1141T,C(!.1
I cerlify Ihat in thr.pnrformonce of the work for which�his
permir is issued,I shall nol employ ony person in ony monner eOILfR,6TU
so ns lo br.camr.subjed lo�he 1Vorkers'Compr,nsa�ian Laws. av�aov.is nni[ INS�ECICP'S 5'uNAill>E
Dale opplitant CO"7PRESSC2.9TU � ROUGH '� �,��
�vOTICE TO APPLICANT: II, o(tcr mnking Ihis Ccrlificate o{ V[NTILhT10Y SVSTEM � FINAL ��
E.empiian, yoo shoold hecomr subjec� to �he Worke�i — _
- Campr.ns,Mion provisions oT the Lobor Code,you musl{arlh- EVAPO'•ATIVE COOIER VALIDATION ,
with ccrnply �:h such prorisions or this permil shnll br �
drr,mrd revokr.d. FU?tinCE� FAU +' TY
LICENSED CONTRACTORS D�CIARATION FLOO4 BiU
I hereby cilirm that I or�licensrd under provis�o�s ci Chep'e�9 F+EATER: SUS:EI:CED UN�T_
�(commencinq wiih Sect�en 7000)oi Divis�on 3 of thr 6us�ness ' �'� =�
and Professicns Cod nd lic . s in full fo�ro nd �'
i �
Lic�nsr.Number Lic.Class , ;;� � ��"�"� �V
Controc�or / a�e�''��'i� i, • • • 0
• .;2
❑ I am e.empr undr,r Sr.c. �^1 w
I Plan check fee � � �� " "�'_ N
8.8P.C.for this�eoson
i PERMIT ISSUING FEE S ' ' ` • �� —
Dain:
� Signoiu�c TOTAI FEE �'_;�!;—r�h
� OWNER-CUILCER DECLARATICN PIAN CHECK AFPLIC�NT
i I hereby oifirm ihat 1 am eKempt irom the Contrec�or's Lice.nsr, ,
Low for fh�foliowing reason(Seclion 7031.5, 6usinrss and NnVE
PlOIPS510�5 COCIP�:
I � �D��E55 �
� I, os owner of Ihe preperly, or my employees w�lh
wnq^s ox thn�r so�e compnnso+�o�,will do+hc work o�d CrtY TEt.h0. \
I �he slruttwr,is nol in�end�d nr offered foi salr.(SetGon �
� 7044.6vsiness o�d Prcfessio�s Codc�. .
❑ OV;Nf 4
I,os ownrr of the preper�y,am r..clusively contracting
wilh licensed conhoc�ors fo cons!ruc�the praject(Sec- �'�,�,� �
tion 70EE,6usfnass c�d Professions Codc). A 4E5 ,
CONSTRUC710N IENDING AGENCY j _� �
I hereby alf�rm�hot iherr.is a cons�r�ction lending agency for
the prriormoncr.of fhe work fo�which Ihis permil is issued CO4Taa�
�Sec.3097,Civ.C.). � � . . . . ...
ADC:
Lender's Name � �
IT Ii M1,
lender's Address
51 Tk I IIC. �C.'
I cerfify tharl have read ihis applim�ion and s�atc tho�ihe IiCENSE N C�A55 .
abovr.iniormotion is corrr.cl.I a�rr.r,to comply with oll Coun�y �
ordinances and S�ote laws relniing 10 building conshucrion,
ond hereby authcri:e re� rt nto�ives of�his Caunty�o r.nicr �
upon r,o ovo- � •i!� ,ro e�far insn=-tion •poses. SEE REVERSE FOR EXPLANATORY LANGUAGE .
Sinnn•v .o!ApPl�can�ar A,=n� Doix . . . . .
..• .
�._ . ` , - .,. .
' '✓ .
' ' , `i� .
, . . 1 . , .�'
/'" - .`' . ' • . ..
, . ' . . �
'
. •/ ' .
Z'�,,0 '' ,. ' ,.
� . � .. . .
N � •
Z .
� .
/. .
. _ �,
. i � .
. `
. . � � ..
'�.. . . ` �, .
. . . N
- J � �
. - : • 0 '
` '1
` , ,
1 . ♦
. .� � .
' ^.�i
, ���O f; N � 'C,
. � ' N � Q t� -' � � �' C
` . N � ...so.o ���Nn • n c ,�
n' `� 'o �
o� �' _;, on -��. ,• � c, O
. `c o �� a_ -- (�� ;a � � Y �
. � o � 5 0 0 �;., �, l7�^ a e�` c.�o _�•c� c:.. Z.
, ,if C � �� 7 F Q�o� �in c�c a �v v�q=-�c a '�= �
�� C m'!' `j ' C ^ n G� C� ��n N O Z 1 tr O O � ....n V "' O ? p CG
f1 C 3 O C: �' ' N f �n O .n �' G
� ?' '-�;s� n � c � � o � —c�' '
c o n� � -, c� • � o .- �, Nr " i;-�; ��,t'. � a 1 „ a oQ �
;, — �; _a . � o v
� O � ' � O :) �£._P O � �""C O .. =C+ �:L. 1i f N' r f C-, p N `^ V 7 [f1
O c. 'a % nnNn "" N � M '% o3 �� °� � ' ° � , ' �:. r� � �
, = cs �C� c� 2� � '-� ��7 v f o n �-n �n ?°: .r = .,,�� � � ^--� �`� ° ��
3 0 3 °.� � N� � ° ^'c.�n° '" T�;`i: °,o'o x �' n c�° 'G"� � n
o :
. � ? ��a�o°''�..�c� �,�'N � G �("T(; �° .'`: T�� "�° ^.'� � n ��
N G- fi O N , O ^ ... ?��'p � 'C1 f% ^l. ^ 7 �'� O N ' � / � I�
; � ^ N � ��� c -'� N �:n o�`- 7 j'c i- c, ,o ?,o � .�
/' ' O N r'� ?� � C'fl � G � � r+ O� V CJ� C — � �...'^ i� �' �_ �n.^ ? r; fi Of
N O C1 tl 3 O n � C Q 4 -{7 7 U y, .4 y. O � O 2) G' O � n .�.. `
• . • S> f� ' ` n �.C�n (�h n K O �' C. (�C'r :S� i?n �, � O � � �j P n
' ' ' O K M �` n V :5 n �G 3•� ? C t1 C% i y, : c N � - � O O
' N�' � � J-C Q O " G�^0 C.�} C-:^ �j =..N 7 j L j C� � l9 .� ��!L
, . ✓ C .nj n G ] �L O^ C �f �'.C f +� � (:'> �' C1'� O .�.. u�n.
, f .y( � � �_ Cl O� � 7 3 +O �'`�� `2 ^'C U��., �t'J p Q� N =. V, N
Y f � % � ��� � � c_ ° � c c� r. r'a � T,� ,� 7 T
. ^ � n � �n U"C� O t� C�T7 " N � _.�
C] U �. �
• �. ^ . '.. U, `i S r- � � 2 p _. 'O O
� �� =t� o � � '" -n = a n _ �
, c �.� �' ° �-? � � � � � i:. � .
� o-�� � � ^,.<
c ° � � o.� c_�o �
• ' . '�N � �` ' , �
�
. G .,� '
� 1 /
. �/