HomeMy WebLinkAbout1152A (5) VlORKERS'CO"::PENSATIONDECIARATION / 1��pp�ICATION FOR PERMIT �
I hnrehy aifirm ihal I hove o certificale of consenl lo sr.lf , �:��j
insurr.,or o rertificote of VJorkr.rs'Co �ensa�ion Insurance, ��
oraYerli�l/��(Sy 3y . ab-1L�� /,� 76�h4� EATING - VENTILATING - AIR CONDITIONING
i � � CE-A16 FEV.�OiBi)
Palit N Cc/iFan
Cc���f�ed copy is hcreby iurnish, �/ COUNTY OF LO$ANGELES � BUILDING AND SAFET — �
Cer�ified capy is iiled w�ih�h��ou�ty building 7nspn- FOR APPLICANT TO FILL IN eu��oi'
Dafe���'on d�,�P/G��rlmr.yn}l�/.7/ (CR�NT C4 TYCE OVLY) ADJ"� '
�-�2�"^,Plimnt /� LOCALITY
NO. TYFE OF AP7LIAtiCE O4 ECUIP:�EM1'T FEE
CFRTIFICATE OF ExEh4PTION F hl WORKER$' NEAREST
CO•'�".PENSATION INSURANCE CROSS ST.
(Thls t�tllon no�d naf b�tomplefad if Iha work Involvad by ABSO4PTION U41T,9TU o�s:��cr ruo r•aoce:�ro e•
the permit tf(or one hundrad dollars(5100)or lass.) � • /
I cerfify ih�l in Ihc performoncc of Ihr.work for whith Ihis AIR HANDII'JG UNIT,CFI.1 y�i)j
(/N'
permit is issued,I sholl nol employ any person in nny manner
so as to bemmo su6jec��o�he\Norke�s'Compensaiion Laws. E?O'LFR,tiTU nrvoovus onie Ih°�CiOR'S SivN4TU4E
Dnle epplicanl CO!r.cRE5SO4.BTU _ _ ROUGIi / i ����
NOTICE TO AF7LICANT: If, ofier moking tl�is Certifico�e oi VENTIIATICN5Y5TEM Fi'�`�AL ,
Evemp�ion, you should brtcome s�bject �o �he Workeri
' Cnmpensntion provisions of Ihc Lobcr Code,yov musl forlli- EVAFC2hTIVE COOIER VALIDATION �
iifi com��ly itli s�cf� provisions or tnis permil sholl be /
dcemed revoked. fURNnCE: FAU C Y �
LICENSED CONTRACTO^.S DECLARATION FLOOR e U -
I herebyoi'Irm ihat I am licr.nsed under provisions o(CFapter9 ����tEq: SU57ENCE� U4IT_
�(tommrnc�n9 wifh Sec�ion 7000)of Division 3 ef Ihe 6usiness � � Vf ��
ond Pro�etsions Code nd my Gc��sc' ' ull forre d r�e . a
' O
licn.nsr,Num6er c G s � ' V
, �
Contr � O
^ V
❑ I am c.empf undcr Sec. y�
Plan check fee a
o.aP.c.ror ih�s.coso� pERMl7 ISSUING FEE S Z
Dnre:
Sgnature TOTAL FEE �-� � '`:'r''
OtVNER�BUILCER DECLARATION �'lAN�HECK ACP�ICANT .. • • • „
I hereby affirm If�nl I am exr.mpl from Ih�Controclor's license ,
Law ior Ihe iollowing reason(Seclion 7031.5, B�siness ond NAh•E
Proless�ons Cod=): �
❑ 1, os owner oF Ihe prop�rty, a my employees wi�h ACDFE55 � e ;,.,j,,��
wc�es cs their scle com;^nsaiien,�v�li do!he wo•k and `
the structurr,is noi in�ended or offere.d for snle(Sec�ion CITv iEL.r'O. � - - i
70-0-0.B�siness cnd Prefessions Code). "� � " ,
� O::MFR
I,as ownr.r af�he prop"ry,am e.clusively con�rac�ing
with Ilcensed conhactors ro consa�cl thr.proje.c�(Sec- nD��FSS ��"���� �`�
�icn 704E,Ousin�ss ard Profess�ons Codr.).
CO'JSTRUCTION LENDING AGENCV �� �7
I hcreby affirm 7Hol ttiere is a conslrvc�ion lending ogency for
the perlormoncr.oi Ihe work(or which Ihis permit is issued �ONT�7�,.04
(Sec.3097,C�v.C.J. .
I ar,ok¢ss • _
lenderi Namr.
i
I lender's Address =
I te.i�f ihol I have�Pnd ihis n,^, litolion ond s�n�e thal ihe SiniE
I Y A UffNSE N Q� � SS . . . . . . _
ebove informai�on is correc�.I o9�ee�o comply w�!h alt Coun!y
ord�nances and Stote lows reloiing io building construction,
I and hereby auihorize reprr.sen atives of this Counry ro enier � - � � �
1 �ron r o ovc- �nr� n � p��iy ior inx�r.c�ion purposes. SEE REVERSE FOR EXPIANATORY IANGUAGE
, �����_ �
+ 5�, :re of Apa'�cani cr Agn�r po�e �
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