HomeMy WebLinkAbout1153A YJORKERS'COhlPENSATIONDECLARATION n ) ���/// �APPLICATION FOR PERMIT
I hernby affhm tha�I hove a cerlifimlc oi consenllo se.lf . �-f�/i /�//w
insorr.,or a certi(icotr.o(Workr�i C pensation In r nte, �6A3�� /� S /�/ MEATING - VENTILATING - AIR CONDITIONING
or a ccr�if� � �$c;,38 , 06.C.)
� / CE.8181F`V.10/81)
Policy N of,�fpany �/�
�j Cr_rrI(ied copy is hc�ehy iurnishe . COUNTY OF LOS ANGELES BUILDING AND AFE7Y •
�y( Ce�rfied copy is I+led wirh the cou dy bu�dmg tns r. FOR APPLICANT TO FILL IN eu��o' :
�7� li ni p rt J n �p2!NT OR TYPE ONLY) ACC�
Dn! plicant IOCaLITv
O. TYPE CF APPIIA�CE O�ECU'�h".`.NT FEE
CERTIFICATE OF EXEAAPTION FR M VlORKERS' ���R�ST
CO"l,PENSATION INSURANCE CROSS ST.
(Thts secl�an nead no}ho tomplaled IF tho work involvad 6y ��SO4PTIOV UNIT,BTU ��Sic��i no � . v;o`t55E�,^.r
Ih�pormf!It for one hundrad doliars(5100)or las�.) � . /1
I cnrti(y�hat in�he perlo�monce of the work fo�which ihis ��R HANDLING UNIT,CFA1 �
permil is issved,1 sholl not employ ony person in ony manne� pOiLER,6TU
so os io bemme,subjed�o�he Wcrkers'Compr,nsation Laws. ncvvpv<t5 onrF ir: t�rce'SSiGvaivaF
Da�e /+Pplimnl C05'.PRCSSC¢.DTU _ ROUGFi ,/,
NOTICE TO APPIICANT: 1I, af�er making this Certilicate of VENTILATION SYSTfM FI4AL �� �
Ecemp�ion, yo� should becoma subjet� io th� Vlorkcrs' _
Compensofion�rovisions of 11�e Lc6cr Codr.,you musl farlh- EVAPORATIVE COO:FR VALIDATION �1
winc �cmply �i:h such pro�eisions Or ihis permit sii�li I��
dPP.mPd�evo4cf�. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION Fi00R tV. �
I hereby a!ffrm!hc+I om licensrtd under provisions of Chap�er 9 I�EATFR: SUSf'ENGED UNiT_
'(commenNng wiih Sed�on 700pJ ol Division 7 oi ihe Ifusiness ' ���41L
ond P�ofess�ons Cafe nA y �ce ' in full forcr, nd�! � • }
a
,� _ O
Licensrt Numbc Lic. ss ► V
�
Contro i • �—� ..I � �.l;1 u
❑ I om exempt under Sec. � ° • ' •� W
Plon check fee a
6.RP.C.for this reasan � n !:�,�?�l Z
� PERMIT ISSUING FEE S
Date:
TOTAL FEE ' " " • ••
signarure
O�YNER�BUILGER CECLItRATION FLAN CHFCK APPLICANT
I hereby alfirm that I am exempi f.om the Controctor's license , _;i f,
law!or the tollowing reason(Section 7031.5, 6usiness and Nnn•E �'�,''�
Professions Co��)'
❑ I, as owner of Ihe prepe�ly, or my employecs wiih ���"ESS
wn,es ns�h��r.oin tompenso�ion,will do�h�work and CITY TEL.NO. `
the slructurr is not in�endrd or ofFrredlor sole(Se[�ion
70dA,6usine.ss a�d Prctrssions Code.�. O�vh�q '� 1 /� ��
❑ I,os owne�oi ihe propPrfy,om eKclusively[onrr�cting �
with licensed coMroctors to construcl the projeU(Seo- �'''��� /
iian 70Ae,Bus�ness cnd P�eiessions Code). A �ESS i .
CONSTRUCTION LENDIM1G AGENCY i � . -� y "
I hereby affirm�har ihe.e is n conslruciion lending agency for '
the perlormoncr.of the work(or which ihis permit is issur.d CONTRaC7 / f.
(Sec.3U97.Civ.C.). .�. - -
ADD'FS � � - �
i ,
Lender's Nomc
�i' t'n
lend=r's Address �^
ST�IE iC. i
� I cert�ty�hat I have read Ihis op�limlion and stoir.iha�fhe tIfENSE NO. C1A55 .
, abovn,info�mation is correct.I agree�o comply wi�h all County
ordinoncrs and St�ie lows rela�ing lo building cons�ruction, _ ,
and herr.6y auihorier.rr.p ese mtrves of ihis Counry�o eNr.�
upo r. Fove� •�-}ior d pe tY fr insp=ction oc�es. SEE REVERSE FOR EXPLANATORY LANGUQGE
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