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HomeMy WebLinkAbout1307A (7) 6VORKERS'COM1IFENSATIONDECLARATION APPLICATION FOR PERMIT � I hereby off�m�hai I havr.a cc���flca�c of conseni to sr.�( insuro,or a coriifica�e of Vlorkers'Compe tion Ins�roncP, o, ,,;: � v�, �se�.,,�,i� .� � 76AJ5=� HEATING - VENTILATING - AIR CONDITIONING � 7CE-AIfl(FEV.lO�BI) a�� Compony _ Ce�uf�ed cepy is hereby furnishad. COUN7Y OF LOS ANGELES ��� BUILDING AND SAFETY �Ceri�fied copy is ed with tha ceu�iy bu�id�ng�nspec- FOR APPLICANT TO FILL IN Bui�Di'�G ,j"�ion�men � ADC�ESS � jy (PRINT 04 TVDE CRLV) Dn��� 0 —Applicant��[`� LOCALITY NO. iYPE CF APPLIANCE OR FpUIPI'ENT ffE CERTIFICJ.E OF EXEPrPTION fR0'.1 VJORKE45' NenaESi r � / C0:'.1PENSATION INSURANCE Ga055 St. � � S� (Thts s�etion n�ad not 6a complalad 1(fhe work involved by �eSC�PTICN U'.I7,e7U e�S�o�Ci No. ow�cf55[D 9r fhe permH is for one h�ndred dollars(SI00)or lass.) � I ceriify iho�in ihe performonce ef thc werk far which ihis AiR F{��DLING UN�T,CF,41 /� permit is issued,I sholl nor employ ony�erson in any monner ! L��c� so as�o becoma subjeci io ihe\7orkers'Compensoiion lows. L'0'IFR,BTU Ai^�OVAlS D<iE IYSf[�iCo'S 5'GNAfIJ�E Dalc npplieanl � CO:•.nRESSCR.BTU,��'��5�.6�Q ROUGH „j�� �e��ciit.eC_� .x/ �� NOTICE 70 APPIICANT: I(, oRer mokin� rhis Cerr�fica�e oi VENTILATIO'JSYSTEM FiNnt o7 �{ '� Ezempfion, you should 6c;oroe subjeU to ihr. 1'Jorkeri ���� U Com�ensotion rrovisinns of Ihe lnber Codc,you mus�forih- EVAF'CRnTR�E COO:fR VALIDA710N wiiii cortiply wilh such p�ovisions or ihis permit snoil bc decmed revoked. vuztince: vnu G nVITY /��, LICENSED CONTRACTORS DECLl1RATION FLOO¢ 6TU�l C7v I hereby af(irm rhat I om licensr.d urder provisions oi Chnp•er 9 N�AT�4: SUSM�DFD UNiT_ (commencin9 wirh Scctlon 7000�of Division 3 of ihe 6usin=ss �'�A« ond Proless�ens Code,and my li�f'n5C�S��IUII(pr�n(]n���{t`C�. �(` � �f y a Licr.nse Numb r��Lic CIos�C.��` , �J /� � CaniraUor poi^__� � ❑ � I om e.empl undr.�Sc.. w Plon check fee ti 13p7A "' 6.RP.C.for this rer.snn PERMIT ISSUING FEE S P Z D te: � Signature __ ` TOTAL FEE � ��� � � � �a O\YNER�BURD"cR CECLARATION I'ln�J CHECK nFPLICANT � "2:Jr.5� � I hr.reby offirm that I am t!Mrmpt from�he Controctor's Litense Law for ihc following reason�Sec��on 7031.5, f3us�ness nnd nlnr.�E • •�.'J 5 5 Q�i Prof?ssinns Codo)� ❑ I, as owne�of the proCP��y, or my employces wilh �CD�CSS ��..��y g,�1 wc�es es,iheir eo�e cempnnsaiion,wdl do rhe werk a�d �he s'ruUurn.is nm iniended or ofFered for sole(Sect�on CrtY TEL NO. . 7044,6usiness a�d Proicssions Cod^). � ❑ O:`:N�R I,as owner of the prep=rly,am ezclusively con�r�c�ing . • wiih licensed con�rac�ors to cons!ruct ihc projr.0(Sr.c• "�•��� �ion 7044,Businrss and Pro(cssions Coc!n.�. ��C;E55 Q� .��� ( CONSTRUCTION LEND!M1G AGENCY Cif iF� .O. I here6y a(firm rhat rhere is a cons•ruciion lendin�a�ency for � , the pr.rformance of rhe work for which this permit is issur.d CONienCiC� +� • (Set.3097.Civ.C.). .. �DGFE55_?/Q Lendcr's Namc ���fP . CI —� TEL.N., /�/� . Lender'sl�ddress - - � ST�TE LIC. �O I cr.rGiy that I have rend this applicatinn ond slnie.Ihat�hr. UfENSE NO. CLA55 („+ � abovc informa�ion is torrncl.I ogr�e to comply wiih nll County ordinonces and S+ate lows relniing l0 6uilding cons!ruc��on, _ , nnd herrby nuihcrize represeniorives of this Couniy�o enter upon the ehovr.�m�n onrd prone�iy fo.insp=cro�pu�pos>. SEE REVERSE FOR FXPLANATORY LANGUAGE (L1 J.�-�---, �_�'� S�qna�ure el Ppplica�l cr A,enr . Dab , . :.,' . ' ' '� . . . . . ,, • , � . =r . .' /' , ;i . ,i . :�� • t ' �. � �� � ' • ' i � . .. . �� ., '�J . , .:, \ `�• .J, ,, , `�� � . , .. � • ' / ` . ' . � 'J . �. _ / •� r �rff� . . /1 . • •rr� Z f'_../��f' N j� •� . 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