HomeMy WebLinkAbout1225A ,W6RKER5'COMPENSATION�ECLARATION APPLICATION FOR PERMIT � I
I hereby affirm that I have a cartificale of consen��o seff
�nsure,or acertificate ot Workers'Compensation Insurance, ���� HEATING - VENTIIATING - AIR CONDIiIONING
or�•certified copy rhereof(Sec.3800,Lab.C.)
CE-BI8(REV.10�8��
P�alicy No. Company -
Certified copy is hereby furnished. CC�JNTY OP LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with Ihe caunty building inspec- FOR APPLICANT TO FILL IN BUIL�ING
lion deparimenL (PRINT OR TYPE ONLV) Aoosess ls J�v. ���l�
Date Applimnt LOUILITY �� � V✓� Q�.�s
NO. TYPE OF AP7LIANCE OR EQUIPMENT FEE
CERT{FICCOMPENSATIONOINSURAN EORKERS' CROSSSt. (� •�p �jYJ� �J{+�D
(This soNion naad noT ba compiotod iF Iho work involvod by ABSORPTION UtviT,BTU DISTRIR NO. � iROCE55E�BY
4ho parmif it for on�hundrod dollara(5100)or Iws.) AIR HANDLING UNIT,CFM �
1 certify that in the parformance of the work for which this �
permit is issued,I shall nat employ any person in any manner � BOILER,BTU
so os lo become subject to ihe Worken'Cvmpensation Laws. navRovnis DATE iNs TOR'S SIGNATURE
Date o'`��Applicont�� COMPRE5SOR,BTU ROUGH
r
NOTICE TO APPL�CANT: If,�aftar making this Cartificate of � VENTILATIONSYS7EM FINqL -
Exemprion, you should become s�bject to the Workers'
Gompensation provisions of the Labar Code,you mus�fonh- evn7oRniive cooteR , LIDATfaN
with comply wilh such provisions or this permit shali be - �
deemed revoked. � puenwce: FnU_GRnviiv �/�7�
LICENSE�CONTRACTORS DECLARATION FLOOR B7u �
I hereby affirm that I om{icensed under provisions of Chapler 9 ��R: $USPENDEO Uwt_
-(commancinq with Sectian 7000)of�ivision 3 of ihe Business - wAtt
and Pro4essions Code,and my license.)s in full force end effxt. , p�I'►nJ ,Q 'j d
vu Q
Litense Numher Lic.Class � _ �/� e � � , - �
91.�LC4�
CoMractor Date �
❑ ti
I am exempt under Sea `, 2 2'S� W
Plon check fee „ �. a
B.&P.C.for this reason ri • • • ° °�5 �
PERAM1IT ISSUING FEE s p I • •2!,5 C
Dale:
Signot�re TOTAL FEE
OWNER-BUILDER DECLARATION PIAN CHECK APPLlCANT - - � � �� �'`�"S
I hereby affirm�hat I am eaempt fmm the Conirador's License � 0&C�—��
Law for the following reoson(Sec�ion 7031.5, Business and NAME �—
P�ofessions CodeJ:
� I, os owner of fhe property, or my employees with ADDRE55 �'—�
wages as thei�sole compensation,will do the work and CITY .�—�"` 7E1.NO.
the str�cture is not intended or offered for sale(Section
7044,Business and Professions Code). � !'
❑ OWNER ���� f
I,as owner of the property,am ezclusively conlracting r [
with licensed confraclors 10 construci the projed(Sec- DDRESS J �S/�'���aS�- GT i
tion 704d,8usiness and Professions Coda). P
CONSTRUCTION IENDING AGENCY CITY u /7�` TEL.N0.9�%�J 7
1 hereby affirm that there is a construction lending agency for �
ihe performance of the work for whith ihis permit is issued CONTRACtOR � �
(Sec.3097,Civ.C.). ,.
ADDRE55
Lender's Name .
CITY TEL NO.C��J.•3��
Lender's Address
STATE LIC.
1 cerfify ihat I hove read lhis opplica�ion ond state fhal the ii�ENSE NO. CLA55
above infarmmion is mrrect.I agree to comply with all Caunty
ordinances and State laws relating to boilding consrrudion, �
and here6y authorixe representatives of�his County to enter
opon the abo�e-menrioned properry for inspec�ion purposes. SEE REYERSE FOR EXPIANATORY LANGUAGE
` ,}.�,.rC� �-L-`�—��i'
W----�-- �
$ignature of ApplimN or Agen� Date .
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