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HomeMy WebLinkAbout1309A (7) 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 I ��7 ����T Sf��o�u.e o(Pnol�can�or A,=n� D:+'n :. � _ . . � . ��' - . � � ; :, � . � ..5 ..., � = . 1 . � _ . '�. . -' � . � ,/. � . • � ,i � ' . r. . . 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