HomeMy WebLinkAbout1150A (5) \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 .
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