HomeMy WebLinkAbout1151A (5) 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
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