HomeMy WebLinkAbout1306AWORKERS' COPAPENSATION DECLARATION
I hereby offirm that I have a certificate of consent to self
insure, or n certificate of Workers' CompensotiRn Insurance,
ofr�'yj {_ar`,'+/'{fed on � f (Sec ? La ) �
❑oll,cyicy No.� ompan �
Certified copy is hereby furnished.
Certified copy fs file with the county building inspec-
tion deportment.
\6t.
Date � _Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not 6o completed if the work involved by
the permlt 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
Exemption, you should become. subject to the Workers'
Compensation provisions of the Lo hor Code, you must forth.
with comply with such provisions or this permit shc!l he
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby offirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7007) of Division 3 of the Business
and Professions. Code, and my license is in full force and effect.
License Number 3� tic. Clas�
��s//C�
Contractor _OoIo JQna�
❑ I am exempt under Se,.
B.BP.C. for this reason
Signature .0
OWNER BUILDER DECLARATION
I hereby affirm that I am e,empi from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Prcfe<-sicn.s Code):
❑ I, as owner of the property, or my employees with
wages as their sole 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 conlracling
with licensed contractors to construct the project (Sec -
lion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm shot there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lenders Name
Lender's Address
I certify that I have rpod this application and sfare that the
above information is correct. I agree to comply with all County
ordinances and State lows relating to building construction,
and hereby authorize representatives of this County to enter
upon tho abov-montioned property for inspection purpose
Signature. of Apalicant or Agnnt Dote
APPLICATION FOR PERMIT
76A351C HEATING - VENTILATING - AIR. CONDITIONING
CE - BIB (REV. 10/81 )
COUNTY OF LOS ANGELES 4� BUILDING AND SAFETY' S
FOR APPLICANT TO FILL IN
(PRINT C4 TYPE ONLY)
BURD'NG
ADDRESS
LOCALITY
�Q 1
vv
NO. TYNE OF APPLIANCE O4 FOU:PV E -NT
FEE
NEAREST
[ROSS ST.
ABSORPTION UNIT, BTU
C'Sr+'cr Nv
Q
C:E.SED er
AIR HANDLING UNIT, CFM
BUHR, BTU
AFPPaVAIS
GATE INSFECTV; S SIGNATUPE
COVPRESSOR, BTU 3b �O
ROUGH
VENTILATION SYSTEM
FINAL
EVAPORATIVE COOLER
VALIDATION
1 3 0 6'A
u•••••a
1•19H00
•• 198005
0 1.30-84
FURNACE: I GRAVITY
aZ FLOOR BTU
HEATER: SUSPENDED UNIT_
- ern L
Plan check fee
PERMIT ISSUING FEES 5�
TOTAL FEE
PLAN CHECK APPLICANT
NAVE
ADDRESS
CITY TEL. NO.
OVlNER
ADDRESS
CITY TEL. NO.
CONTRACT,
r'
ADDRESS%Q OP __ _ • 1 tyt/
r fes+. Y/� TEL. -03E21-42_1STALE
LIC. /
LICENSE NO. [LASS (�
SEE REVERSE FOR EXPLANATORY LANGUAGE
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