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HomeMy WebLinkAbout1151A VlORKERS'C0.4".FENSATIONDECLARATION � /"�'���pp��CATION FOR PERMIT � I herr.by affNm that I hove n certificatr. oF consent�o self r..�f/ insure,or a crni(ita�e af 1Yorkrrs'C pensali i nsuroncG 76A_A�C !/1 TING - VENTILATING - AIR CONDITIONING or a ccr�i c, • r 5 .3E .) � �r' . CE�P 8(REV.IOi81) Polity pon, � � Cc�rred co�y is hereby furnis � COl1NTY OF LOS ANGELES BUILDING AND SAFETY� Ceruflnd cepy�ips f�iled wirh thn.coumy b 'Iding �s o- FOR APPLICANT TO FILL IN nuim�n �100 �� ���P(/y/y �FRIN7 CR TYPE CNLY) �DCRF� _ Dn�__��'������V"Prlicani . IOCALITY � NO. NPE OF AP?IIANCE OR ECUIP!;ENT fEE - CFRTIFICATE OF EXEAIPTIOY ROh1 VJORKERS' N[ncESi CO"J!PcNSAT10,1 INSURANCE CRO55 ST. (This sactton naed nol be complatod iF tho work Involvod by �g�RPTION UNIT,BTU ��s�xic�no. reec[:s,p sr _ tha permil Is For one hund�ad doliars(SI00)or Iess.) � �v � AIq fiANOLING UNIT,CFM / I ce.r�ify thot in the periarmancn oF the work for which this �/ permit is issucd,I shall nol employ ony person in ony manner so as�o betomc subject to Ihr.NJorkers'Compr.nsalion Laws. eO�IFR,ATU AGoqOVFlS onr[ 'JS�FCiOP'SSIGNAI�P[ Date "Apriicant CO'.'�FiE5504,9TU � ROUGN ��. �J''� NOTICE TO hPPLICANT: If, after moking Ihis Cartifim�e of VFNTRATICNSYSTFhS �W�I Exemption, you should becomr. subjett 10 Ih� 1`✓orkcrs' __ Compr.nso�ian provisions of Ihe Lnbor Codc,you must iorth- [ynPORnTIVE COOIFR VALIDATION �1t w,i�h c�,•,ply ;•,��h =::ti p ...,_,.: c: this perrit shall b� —. 1 dr.emedrevckr.d. IURN�CE: FAU Y � � LICENSED CONTRACTORS DECLARATION FLOOR !�U I h^reby efFirm�hof I om licens^d under provisio�s of Chop!cr 9 SUSP[h:F� U+lli I (commenting wiih S�cNon 7000)of Divis�on 3 of the Bus�ncss HEATCR� ��� ii and Profess�ons Coc{� nd my fce � iull forcr nd % } a / � � O License Numbef tic.CI < , V , J . . C ConlrQ+ . ❑ � I ^� � ; V I am exempt und�r Sec. u � Plcn theck fee : � • �8 y 6.RP.C.for ihis rcason PERM17 ISSUING FEE S � Do�r: I • .,. '.i'., signai��c TOTAL FEE � - - 01HNER�CUIICER DECLARATION FIAN CHECK ACiYI�t.NT I hereby ef(irm ihat I em exrmpr(rom�he Con!reclor's licrtnse , Low(or Ihr,followint�renson(S�tlion 7031.5,Businnss and NA!�.E Prcfessions Codej: '���'�' ��' ❑ I, os owner ol the p�operly, or my employr.c5 wilh �'�C�E55 or.?5 os the��sole tompr.nsolion,will do�h�work on�1 ��TY T[L,NO. l ihn s!rutfure is not inl=nded cr offered fcr sale(Seclion 70�7E,Bus�ness and Pro(essians Code). �J O055'N�4 I,os owner ef the prope�iy,om exclusively conlrncling with licensed controc�ors�o conslruct the projetl(Src- '�'��� � A �F55 lion 704d,Business�nd Prcless�ons Code). 7 �a CONSTRUCTION LENDING AGENCY � I herr,by aff�rm thot ihere is o conshuttion lending o,ency for Ihe periorman[P of the wo�k for which this permif is issurd �ONTRAC...�t (Sec.3097,Civ.C.). . . . . . . . . ADDFE55 � � �- . . .. lend:r's Namc T NO. ���dP;S ndd,�:s �1•1E iC. � I cernFy ihni I ho�e recd rhis applica�ion and s�o�e�hot thrt LICENSE NO / C�a55 . . obove informoiion is cnrrecr.I a9re�Io comply wilh oll County ordinonces and S�al�laws relo�ing to building tonslrutiion, and herr.by nuihorize�.pm eNo�ivns of ihis County to emer . � up iho ab��en en� ,� prop�riy for in`snetr' p�- r SEE REVERSE FOR EXPLANATORY LANGUAGE I) c:r S�g .�r�rw of Ap�liranf or Aae�r Da�c ' �. , ,-- ' � .. . . , . , _. . �., , � • " . ' . . � ,: . � . ' . � �� . ' � � � � . • . . . � • � , . . . � ' . � . • � . o � � � N , . 2 O � . . � ' � :. , , . ' . � . ' . , AE . . . �: r '• ' �, . / ' J .. �` /• � y . � , , � N. .�. �' . . � � o� �. , ` . N\ �-' ' r �� \ // , . ��. � r . ` ` . /� + ' ' � i f i . . O f� M r'� • ��� � . � . . N O � _. G � � -`.". ' . � "�O O n � 7 C. � � �n,. 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