HomeMy WebLinkAbout1154A (5) WORKERS'C0.'�"•FENSAlIONDECLARATION �,�j��App��CATION FOR PERMIT �
I hcre.hy affKm ihat 1 havc a ccrtifica�n oi conseni�o self
insure,or a certificoie of�"lorkers'Ca ensa�ion Insura a, �
o,�«�'i;��5r.c.3000, b. 76n35:C HEATING - VENTILATING - AIR CONDITIONING
� CE-AIB(REV.IOi81)
Policy� o��ny � "J^� . �OUNTY OF LOS ANGELES BUILDING AND AFETY " "
� Ceriified copy is herr,by Furnis e . ///�/
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Ce�rhed copy�s f�led with 1he counly bui ding inspsc- FOR APPLICANT TO FILL IN BUilo;',
!��d� q�r���P��,[[ � (PRINT CR TVPE O�:LY) �D7Ri _ i �
Date���-,j����,�,—'�,r'�'plimm IOCnLiiv
NO. TYA'OF APFLIA�CE CR FQUI�MEhT FF�
CERTIFICATE OF EXE1rPT�ON F Oh1 W02KER5' �EnRESi
CO.M.FENSATIO�J INSURANCE CRO55 S7.
(Thi�sacllon nvad not ba comploled if fh�work(nrolrad by ABSGR�TION U41T,BTU p�5iv��T r,p. r�OCES�FD r
th�parmH ff for ona hundrod dollorf(5100)or I�st.) q�R HAhDLI'"G UNIT,�GPA �/
I cnrtify�hot in the performonce n!the work for which Ihis ��
pe.rmil is issued,I shall not rmploy ony pe�son in ony monner
so as to become subjecl io ihe\Varkr,ri Comrensofion Lows. BOILER,B7U AenpOV/l5 DaiF I .PEC707'S 5'GNA7lIP�
Do!e oppliconl CO:'PRCSSOR,OTU ROUGH ����
NOTICE TO APPLICANT: 1I, afier making this Certi(icoie oi vENTILAiICN SYSTEI.1 Fih4i ��[j'
Exempiion, you should hecomr. subject lo Ihe lVorkers'
Compensct�on provisions o(Ihr.Lobor Code,you musl iorfh- EVAi'CRATIVE COOIER VALIDATION -�1 —
wiih comply with suth provivons or Ihis permil shoil bn �
deemed revekrd. FUR!iA�E: FAU � T �
IICENSED CONTRACTORS DECIARATION F1004 i
I hereby oHirm fhol I om liconsr,d under provisions of Chap�er 9 SUS%END'eD U1:iT_
�(commencing with S�c!ion 7000)ol Division 3 of ihe tius�ness HEATER: ���
"nnd Professions Cod .. d 'cen � full force d r.f -1. �
�/f a
JLicense Numbe.r / ic.C oss V�
, �
I Conho� � � ' i �
l ❑ I om exempt under Sec. v � ''I � ?�� '� w
Plan check fee , . • • , a.
B.AP.C.for this rrtason � s ^ �
PERMIT ISSUING FEE S � , ':n r• �
Darc: .. .
S�gnoturr. TOTAL FEE � � _
O�VNER�6UILDE2�ECIARATION tt:N CH[CK ACM�CaNT
I hr.reby offirm th��I om ezemp�from the Conimc�oi s license
lnw for ihe follow�ng rr,ason�Sect�on 7031.5, f3usinrss and Nn!ri ' u • ., — ....
Profr,ss�ons Code):
❑ I, os owner oi Ihr preperiy, cr my employees wirh �DCp:55
ag�s as!h=ir so��comp��sa'�on,will do ihn work and
thr.structurr.is not intend^d or offc�ed for solt±(Setlfon CiTv iEL.n0. l
704n,Businr.5s and P�ofessions Code). I
❑ OWNER
I,as own��of fhe properly,nm r.�clusivcly canlraclin�
with licens?d tontraclers la construct the projett�S�c- '��^��� �
fion 704A,Business o�d Prolr.ssions Codc�. �D^7E55 , �
CONSTRUCTION IENDING AGENCY , �� 7,..�
I here6y oilirm ihat�here is a construc�ion lending agsnty for
iho performonce ef fhe wo.k(or wh�ch ihis permit is issued C04TRP .�
(Sec.3097,Civ.C.). / .
ADD7E5
Lend=r's Narie
,1T
lender's Address � - "
ie
I rerfiiy thnt I hnvr.rend this npplico��on and s�ate thpl Ihc �ICFNSE N . �(A55 � .
a6ave infcrmotion is corrrtt.I nq�c�to[om�ly with all County . .
ordinances ond Srare laws reln��nq lo bu�ld�n�mnstruction,
and hcreby auihorize repres n!n��r.s of ihis County to r.nier � � -' � ' � �
�pon i!• abov�-m ii :�rc ..n for ins�.�n pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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