HomeMy WebLinkAbout1309A woRKeas•co:".PENSATIONDECIARATION APPLICATION FOR PERMIT �
I hereby afli+m ihat I have a cerlificnle of consenl to self
'nsure,or o cerlifica�e of VJarkeri Comprnsalion i����a��a, HEATING - VENTILATING - AIR CONDITIONING
or�Q cr.rtifir_ .d co�Y)h�eof(Sec.3fl00, ah.�� '��A35.�
fJ Q/7A� �� � �.aIB(k°V.10/81).
�Ol�y�lA'��•s/�'S Company :.+/�J:�L(J
� Ccri�i�ed cepy is hcreby furnish d. � COUNTY OF LOS ANGELES� ��� BUILDING AND SAFE7Y
� Certllied copy is file.d with�hr.caun�y huilding inspec• FOR APPLICANT TO FILL IN U BUROiNG
lion de criment. AD��E55
�j`P (O41NT O�TYPE ONLY)
Dotc�pL�2— —Applitant _ LOCALIT
NO. TYCE OF AF�LIAhCE OR FGUIP:'ENT FEE �
CERTIFIC!•E OF EXEM.PT�ON FROM Vd02KER5' NEI4REST
' O:"•FENSATION INSURAn;CE CeCSS ST. T �
(Thit set}lon nasd nof 6v tomplHod ff Iha work Involv�d by �g�RPTION U.'JIT,BTU �Sf��C7 no cao:[s'o�r
1he parmit If(or ona hundrad dollars(SI00)or less.) /
A�R HANDUNG UYIT,C«d / �
I certify ihar in the periormance of�he work fer wh�ch�his d—u����
prrmil is issued,I sholl nol employ ony�crson in any monnrr eOiLER,6TU
so os lo betomr.subject to the Workers'Compensaiion lnws. � nc^oovais DA+E w�nrciea�s si�vnruse
Dafr. AAplimnl COV.�f7E5SOR.BTU �J ROUG�� � iy*i�y7,�
NOTICE 70 A�PIiCANT: If, afrcr mok�ng ih�s�crf�ficare of VFhTIIATIOV SVSTER7 FINRL � �j�{j�.u.�-�
Eacmp�ion, you should become subject to the \Vcrkcrs'
Com�rnsolion provisions of Ihr.Ln6or Codr.,yau musl for�h- EVA�O4ATIVE COO!FR VALIDATION
with comAly with su:h provisions or lhis permit sh�ll b?
dermed revoknd. FURNACE: FAU _G��VIT� Y
LICENSED CONTRACTORS DECLARATION F1004 BIu_�IJ/�D'fl— -
I herr.by cifirm Ihat I nm lice�sed vnder provis�o�5 of ChoprM 9 F��AT�q: SUSFfNDfD fT U":!f_
(ccmm�nting with 5?:tion 7000)of Div�sion 3 oi�he Ousint!ss v�a« y
and Professions Code,end my I��ensA is in full force and rf(ecl. �e�� n.
� , 0
Licensc Numb^r�����Cla�ss������/
/� K
CoNractor Da+r. �
� I nm exempl under nt. V
Plan check fee W
B.BP.C.for�I��s recson
�1 �Q9r1 �
PERMIT ISSUING FEE S D �� � � � �a —
D te: •
5.����r r�c� TOTAL FEE � . � 3 9.5 0
OPlNER�6UILDER CECIARATION i'LAN CHCCK PFCLICANT .
I hereby oNirm thol I em exer��1 irom Ihe Conrraclor'S License ► • • ���J��:
Law for the foliowing rcason(Section 7031.5,Dusiness and Nn�:E
Proiessions Cadr.): O�.J U—$�l
�,^.CR'S5
❑ I, cs ownr.r of Ihe pren^�1y, or my cr�ploy�rs with �
woges as their sole compcnsction,will do!he werk end CITv iEL.NO. �
�hc s+ruUure is ne�imended cr offered fo�solr,(Section
7044,�v5inp5S O�d PrOfeisicn5 Codc). OWNER ��O � J
❑ I,as owne.r ef the praperly,am e�clusivr.ly[on7rac�ing
with I�tensed can!rnUors to tons�r�cr the projecl(Src- ��`q�� _/_^d
tion 7044.Business and Preiessions Code). ADC2E55 ���y _
CONSTRUCTION IENDI�G AGENCY Ci,' ,i.n0.
I hereby aifirm ihat Ihc�c is n construuion i?nding og^nty for ,
the performance al ihe wark(or which this permir is issued CONTRnCT��
(Sr.c.3097,Civ.C.). ..
AD'JRESS �
lPnder's homc � — — —
' TEL.N.
Lendcr's ndd�ess ���/�—
STAIE UC /1 7/f
I cerlily that I havc read!his opp�i[oHan and s�n�c�hol Ihc UCENSF NO CLASS C� �v
ebove info•maiion is cwrrtcf.I agree�o comply wiih all Coon�y
orr±innncr.s nnd S�o!e laws rclolin9 la building cons!r�ti�on,
ond hcrnby a��horize representati�es of this County io en�er �
���he bo�w�+e !�oned propariy for��spect�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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