HomeMy WebLinkAbout0393AWORKERS' COMPENSATION DECLARATION
I hereby affirm [hat I hove a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
oro certified cpyothereof (Sec. 38DO Lob. C )
Policy Nc Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion de artment. /
Date. Applicant r fl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed IF the work Involved by
the permit Is For one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date applicant
NOTICE TO APPLICANT: If, after making this Certificate of
s'ption, you should become subject to the, Workers'
Jensotion provisions of the Leber Code, you must forth.
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm •hot I aro licensed under provisions of Chop•er 9
commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number-`--C Lic. Closs
Y
Contractor /I Dole.
1 am exempt under Sec.
B.BP.C. for this reason
Date:
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the. following reason (Section 7031.5, Business and
Professions Code):
11 I, as owner of the property, or my employees with
wages as their sale compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Cede).
CONSTRUCTION LENDING AGENCY
I here.hy offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and stole that the
above information is correct. I agree to comply with all County
ordinances and ate laws relating to building construction,
and hereb a t r re representatives of this Co my to enter
upon the e a len Toned properly for inspect o purposes.
S.Ono.0 of Appnmm or Arent Daae
NA35rC
CE - 818 (REV. 10/81)
1 bvlL7
APPLICATION FOR PERMIT 3P aHEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
PRINT OR TYPE ONLY)
BUILDINGADDRESS r N' It L fJ
LOCALITY
JNO. TYPE OF ArPLIANCE OR IOU'PPIENT FEE
NEARESTCROSSST.
ABSORPTION UNIT, OTU
ISIPICI Na
Xb
F -O Escm By
AIR HANDLING UNIT, CFIA
BORER, BTU APPROVALS DATF INSPECICR'S 5'GNATURE
CO:•PRESSOR, BTU 6 U b ROUGH
VENTILATION SYSTEM FINAL
EVAPORATIVE COOLER VALIDATION
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FURNACE: I R VIjV Rq
FLOOR B1U) U
HEATER: SUSn N.^.ED UNIT
WALL
C
Plan check fee
PERMIT ISSUING FEE S
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRFSS
CITY TEL. NO.
OWNER Tjt`aMAIL
ADDRESS L_ tf 'Lie,
t
CITY L, -L. NO.
CCNTRACTOR
ADDRESS
CITY f_djDJt iEl. NO.Io
STATE IIn
LICENSE NO. /) (
CLASSC.
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