HomeMy WebLinkAbout1306A (7) WORKERS'COf,qPENSATIONCECLi1RATION APPLICATION FOR PERMIT �
I hercby affKm ihai I have o cer�llfca�^oi tonseni to self
nsure,o.a ce�iilkoie oF Workr,rs'Compensa�ipn Insu���ce, �bA�y<� HEATING - VENTILATING - AIR.CONDITIONING
o�crri{t��l on���f(Sec:�0�a 1 eE-a�n(RFv.toiBt) '
f't=r7 r--�
a�y no. compony_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Ceriified cepy is hereby furn�shed. ��r! �S
Crsrtified cepY�s f�ie w�ih ihr.couoiy bu�ld�ng��s�ec- FOR APPLICANT 70 FILL IN � �u�io�Nc
tion c�pporimclll. �,r (F71Ni C4 TYi'E ONLY� ACC�E55
Dafe �_SJ _Appliconl 1i. tOCALITV 11 . -- '
NO. TY:�E CF A�PUANCE OR FOU:P"JFNT FEE G��
CERTIFICATE OF EXE74?TICN FROM WORKERS' NEaREST
COMFENSATION INSURANCE [RCSS ST.
(Thls sacMion nead no}6a complefod ii�he work tnvolvad by �BSCR�TION UNIT,6iU c�s�+�cr nv � v;;�E.:fD BY
tha parmN Is lar one hundred dollors(f100)or less.) pl�HANDLING UNIT,CFM /
I certiiy tho�in Ihrt periarmance oF the werk for which�his C D �,v�C�
�r,rmit is issued,I sholl not employ nny person in any monner e0'1E4,BtU
50 OS�O�.`PCCTC SUb�CC��O iFIP�Y(IfkClS�COR1(If`f1501iO11 LOM/S. ���An�AI$ �ATE INS�ECiC�S SIGN4fL'9� �
DaM Ap��icpnl � C05'�RESSCR,9TU��b��71�EY\] RO'JGli � `� �Y �
NOTICE TO AFPIICANT: I(, af��r mnking ihis Ceriificate of VENTILATION SYS7FM11 FiN?i ,2. �l fG �.^N�-`�
Exemptian, you should becomr. subj^ct io thr 4Vnrkr,rs'
Compensation provisions of th�La6ar Code,you musl fcrlh- EVAPOPnTIVE COCIER VALIDATION
winc �omnty wi+h s�irh ��ovis�e�s cr !h�s ; ....�! :h�!I 6r.
dPrm=d rrvoked. n,m � fU2NACE: FaU �R�VITY
LICENSFD CONTRACTORS DECLARATICN e1 F100R �TU
I hereby affirm thol 1 om licensed und^r provisions of Chap�=r 9 SUSRt�'CCD UNiT_
�(comm�ncinq with Srction 70aJ)of D+vision�of ihe E3usinr.ss N��TE4' Y!A L
ond Profrssicns Cod�,ond my I�cense,is in full force nnd r.ffecl. � � " }
j7� /�_+� R
License N�mber �e�w lic.Closs v��(C� , V
Conlrnclor _�ole J QN� �
❑ I om exempt undr.r Se�. uVi
Plan check fee �.
8.8P.C.for this rcason '�
PERMIT ISSUING FEE S 5� � Z
�.Q P TOTAL FEE `� :� 3 Q 6'�
s,naru,c
O�JNER�9UIlDER DECLA.RATION �'LnN C��`.CK AP!'�ICn.":T u• •'• • •S
I hereby aifirm+ha1 I am e.r.mpi irom ih�Con�r�cfor's li;ense �
law for the following rroson(Snclion 7031.5, Ousinr.ss and NA�'E � • � (��E Q O
Prcfo<s�c.^.s Cod^): �
❑ I, as ownc�of Ihe o t or m em io rrs w�ih ��%zE55 • • � 9�Q O`
pr p�r y, Y P Y�� ,
wone.s os their solc compenso�ion,will dn fhe work ond CiTY TCL.NO.
�he srruciurc is nat intended or offerrd ior salc(SeU�on ��,,3 Q+$Q.
7044,6us�ness and Prolessions Code). .
OVlNER
❑ I,as owner of Ihp property,om exclusively conlrncling '. `
. wi�h licens=d con!rnctors to constrott the projecl(Sec- �C�RE55 Q '
�ion 704a,�usinnsz and Professicns Codc).
CONSTRUCTION LENDING AGENCY Ciiv iFt.NO. �
I hereby olfirm the7 there is n construc�ion Innding�gency for ►
�he p?r(ormonce of thr.work for whlch this permil is�ss�ed CO^:iRPCT^
(Sec.J097.Civ.C.J. . . .
noeoess� O�-- — � 1 t� . -
Lr.ndr.r i Namc � —
� TE�.����/-vG-3�
lendcr's�ddrrtss
I ceri�f thot I have�read rhis a licaiion and sia�e�ha�ihe SiAIE ' llC. / ]�
y pp IICEhSF.NO. [LASS C+ 0�
obove iniormo�ion is cerrecL I agree�o comply wiih all Coun�y
ordlnonces and S�a�=lows�cloting to bu�ld�n�cons��uc�ion,
ond hereby a�thorize rr.Aresen+ntivr.s of Ihis Couniy�o en�er
upon th�obovr,�menlionr�l proprrty fer inspec��on purposc SEE REVERSE FOR EXPLANATORY LANGUAGE
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