HomeMy WebLinkAbout0776A WORKERS'COMPENSATION DECLARATION AppLICATION FOR PERMIT
I here6y affirm that I have a tertificate of consent to self /')�; /
insore,or a cenificate of Workers'Compensation Insuiante, (f/
. or a certifi � o y r o (Sec.3800,Lab.C.) 76A364C g HEATING - VENTILATING - AIR CONDITIONING
r CE-818(REV.10/81�
Paolicy No. mpany COUNTY OF LOS ANGELES � BUILDING AND SAFETY #"�
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDiNG
� fion depar} t. ADDRESS
(PRINT OR TYPE ONLY)
Dnte�Appliwnt IOCALITV �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM ORKERS' NenaEST
COMPENSATION INSURANCE CR0.5557.
(This sxtbn noad nof ba complotod IF tho work in.olvod br ABSORPTION UNIT,BTU oisrRicr No va ss sr
Iho pormit I�for ona hundrod dollars(i100)or lesc.) �
I certify that in the performance of the work for which this A�R HAN�LING UNIT,CFM
permif is issued,1 sholl not emp�oy any person in any manner gpILER,BTU
so as to become subject to ihe Workers'Compensalion Laws. nPrcovnis onre INSFECiOR'S$IGNATURE
Da1e �ppliconf COMPRESSOR,BiU ROUGH � G
NOTICE 70 APPLICANT� If, a{ter mukinq this Certificate of VENTILATION SYS7EM FINAt �
Exemption, you shoufd become subjec� to �he Workers'
� �pensatioo provisions of Ihe Labor Code,you must forth- EvnPORn71VE COOtER � VALIDATION
comply wi�h such provisions or this permi�sholl be
ueemed revoked. FURNACE: FAU R ��Y
LICENSED CONTRACTORS DECIARATION FLOOR i
I hereby affirm thai I om licensed under provisions of Chapter 9 SUSPENpE� UNiT_
HEATER: WALL
��commencing with Section 7000)of Division 3 af ihe Buslness
and Professians C.ode and my license is in full force ond effect. �
License Number-��la��ic.Class�� , V
�
Contfact Re �
o '"
I am exempt under Sec. �
Plan check fee a
8.8P.C.for this reason N
PERMIT ISSUING FEE S z
�ate:
Signoture TOTAL FEE
OWNER-BUILDER DECLARATION PtAN CHECK APP�ICAN7
I here6y affirm that I am exempt from the Con�rador's License . � ,_,„ ��%,��r
Law for the fo�lowing reason(Section 7031.5, 8usiness and NAME �
Grofessions Code): +' " • e • •�
❑ I, as owner oF ihe property, or my employees wifh AD�RE55 � . •ii ¢C�
� wages as their sole compensation,w�ll do the work ond _
fhe stroclure is not infended or offered for sale(Section QTY TEL NO. � .,_
7044,Business and Professions Code). � � � �
OWNER ! � v `
❑ I,as owner of the property,am ezdusively coMracting �L u i,� C—��i
with licensed toMracfors to construct the projeci(Seo- qDDReSS ' Q � �
tion 7044,Business and Professions Code).
CONSiRUCTION LENDING AGENCY ��ry h!e O 1EL NO. 3�--.��p['J
I hereby affirm that there�s o construttion lending agency for !�
ihe performante of the work for which this permi�is issued CONiRnCtOR � �,
(Sec.3097,Civ.C.). _
ADDRE55 � O � � . . . �
Lender's Name /
CI1Y � �TEI.NO-�3 2 /
Lender's Address ��
STATE IIC. ^
I certify that I have read this opplica�ion and s�ate that the IICENSE NO. O CLn55 l.�
above information is correct I agree b mmply with oll County
ordinances and State laws relating to building construction,
and hereby authorize representatives of ihis County lo enter
upo the abo�e-me tio d roperty for insped�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrwture of Applicant or Agenr ��� �
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