HomeMy WebLinkAbout0864 (4) 4YORKFRS'CO.lFENSATION DECIARATION � I hcreby o(firm�hot 1 hnve o cerrfico�c of conscn��0 5��� . APPLICATION FOR PERMIT �nsure,or a cerrlica�r.of Worknri Compensoron��s��a�ce, • HEATING - VENTILATING - AIR CONDITIONING or a cr.rtified copy�!�ereof(Sec.3800,Lob.C.) 76AJ�eC ��. S+�G11190 A Sunerior i�ational CE-818(REV.10/tll) �cy o. Compon�+ COUNTY OF LOS ANGELES BUILDING AND SAFETY Cerlified copy is hereby f�rnished. � CPlIiIiPd C PY is filed wi�h�he tou ry �ild�,g��sped� FOR APPLICANT TO FILL IN eu��o:NG �io .eparmenl. �D�RE55 1371 Ran eton Dr. � �P,�INT O4 TYPE O\LV) �Do�c Applicant ti L 1OCAL1TV Diar�or.a Bar \J �O. TViE OF Ai+o�IANCE CR EOU:P:•FNT FEE ERT ICA E OF EXEf.1aTl .ROM L'lORKERS' nFnR[Si CO:'PENSATIOP I SURANCE caosssr. Glenbrool: (Thi�s�etion nosd not be com eod if Ihe werk involvad 6y p'��Q'��`7N UNIT.ATII o�ir�u�o �voass!o xr fh�pa�mH fs►or ona hundrad dollars(f100)or la�s.) �� I cerlify�hnl in Ihr,per(ormonce ef Ihe work for which this AIq fiA�DIING UNIT,CFA1 'Z permil is issu?d,I shall not r.mploy any�e�son in any manner � so ns to becomc subjett�o rhe Nor4ers'Compensn��on Laws. e0'IFR,RTU pF�o0VAl5 AaTE NSMC702'S 5�4N4T�PF Datc Applicont CO'!PRE5504,BTU ROUGH I�OTICE TO APPLICANT: If, oftoi r�oking ihis Cr.r�ificaie of VEr:TilnTiOV SYSTE�.1 FiunL Exemp��on, you should become svbjecl to 1hr. LNork�rs' Comnensa�ion provis�ons of�hc Labor Codr.,you musl iorih- EVAf�O4ATIVE COOLER VALIDATION winc �omply wiih such prov�siens or Ihis permil sholi be deemedrevoked. FURNf.CE: FnU `-G4'V�TY ^ ��'' IICENSED GCNTRACTORS DFCIARATION I FIOCR BTU Sf�F/l-�J`�i JI� � I hereby a!(�rm�hai I am licensed u�der p�ovis�ons of Chnpter 9 M�ATER: SUSPCM1JED L'NIT_ (commencing w��h Sec��on 7000)of D�vision 3 oi�hc Business ' �"/A« r and ProFesslons Code,ond my I�cense is in full force and e.F(ect. �y L�cenSrtNumbrr 3151C3 �,ClossC C20 p$�� a co���o ` � I?�5 , � � o ;'d:K�,ii�j u ❑ I nm .�empi under Sec. plon cheCk(eC � � �2 r � . P.C.for�his reason � �."� Z p�1e: PERMIT ISSUING FEE S G . .2 Q,j(�� TOTAL FEE „Q �j� �C G�'� � signarurr. _ . OLYNER-BUILDE4 CECLARATION �l�N� . FP�I�ANT I hcreby a�firm Iha�I am c.emp�from�he Con�ra:�or's License , Law fo��hc followin9 reoson(Sec��on 7031.5, 6us�ness and N4�•.E Professions Code�: ❑ I, os ow�er of�he prcper�y, cr r�y emptoyees wirh � ��DRESS wo�rs os iheir sole compensotion,will do Ifie work ond Ci{ TFL.NO. ihe.slr�Uure is not iniended or oifered ior sale(Sec�ion i 70E4,Business and Pro!essions Code). ❑ O:':tiER �;;�rles Bunberger I,os owner of�he preperty,am exclusively confroc�ing wiih Gcensed com.ac�ors io construci�he project(Seo- ��'A�� �` a0�2E551371 ?RP.R �tC?? Dr. lion 70A4,Busire:s ord Profe!sians Cedr.). C �� y�,p� b V CONSTRUCTION IENDING AGfNCY ��T�jiaMond Sar TEi.hcS��-6607 I hereby affirm tho�ihere is a cons�ruc�ion Innding agency For ► �he performance of the work for wh�ch ihis p^rm��is issued CONTRaCTC�0i1n a. j✓,a_r,'-,lI] �'i�_.& h.C (5=c.3097,Civ.C.). noc�ess�c,2 Ft. �3o^it= Ave. �� L \ �'� Lrnder's Nome °T�aGr. Dina� rE�.r,o 5°4-2901 Lender's Addrr.ss " sTnre 3��_03 uc CLO I tertiiy tha�I have�ecd�his applicaiion and stn�e ihat ihe IICFIhSE Np C�nSS � . . obovc in(crma�ion is torre[t.I ogree lo comply wi!h all County ord�nanc�s and Sto+e lows rela�ing io bu�iding consirociion, and herc a�rF�r ze represen�aii� s of this County to enter � �uR�ty,�h. o��men in ed rnoe� �r inspec�n. porp scs. SEE REVERSE FOR EXPLANATORY LANGUAGE � �. � \ �1 / /S�no�ure af A;plicori nr Age�i Do•� � t� , . ' � � ' ; . ' ' � :. � �o ._. . � ' � . o � � N , ' . 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