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.�-�---, �_�'�
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