HomeMy WebLinkAbout1168A WORKERS'COMPENSATION OECLARATION APPLICATIOM FOR PERMIT �
I hereby affNm ihat I have a certificate af consent to self
insura,or a certificate of Workeri Compensation Ins��ance, ��� HEATING - VENTILATING - AIR CONDITIONING
� or a cenified copy lhereof(Set.3800,Lob.C.) . . •/
CE-818(REV,10181) - .���'#3�f �
P❑olfcy No. �n��«t�� ComPa^Y S'tl't0 FUIIa /
Certified copy�s hareby furnrshed. TR$ 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY PH# 4
m Cert�iad copy is filed with the county building inspec- FOR APPLICANT TO Flll IN BUILDING
lion department. - (PRINT OR TVPE ONLY) AODRE55 20764 East Rim Lane
pate�Appl iront LOCALIiY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
� CERTIFICATE OF EXEMPTION F M WORKERS' � NEaRESt
COMPENSATION INSURANCE CROSS ST.
(ihls wcflon need erof 6Q comp��ted iF fh�work involved by ABSORPrION UNIT,BTU DISiRICE NO. FROCESSEO BY
tho parmll ts for ona hundral dollon(5100)or(ess.) � � �
I cerfify Ihat in the performance of fhe work for which this A�R HANDLING UNIT,CFM
permit is issued,t shall nat employ a�y person in any manner gpilER,BTU
so as to become su6ject b Ihe Workers'Compensofion Lows. avveovn�s onte INSPEC70R'S SIGNATURE
Dafe Applicam COMPRESSOR,BTU ROUGH �
NOTICE TO APPLICAN7: If, afler making this Certificale of VENTILATION SYS7EM FINAL
Exemption, you shouid become subjecl to the Workers'
Compensation provisians of ihe La6or Eode,you mvst forth- EVAPORAnVE COOtER VAUDA ION
with comply�wi1h such provisions or Fhis permN shall be
deemed revoked. � FURNAfE: FAU GRAVITY
LICENSED CONTRACTORS DECIARATION FLOOR �7U
I hereby affirm fFwt I am licensed under provisions of Chapfer 9 HEATER: SUSPENDED UNIT_
�(commencing with Section 7000�of Divisian 3 of tha Business ' Wa��
and Professions Code,and my license is in full force and effect. �
G
License Num6er�._...����Class��_ '. " � V
�
CoMroUor TrvinPL_4Qat pore 7-23-57 0
� 1 am ezempt under Sec. - . V
Plan check fee W
N
8.8P.C.for this rea:on
PERMIT ISSUING FEE S �
oa�e�
TOTAL FEE y _ � � � ,���.
Signalure �
O�NNER-BWL�ER�ECLARATIQN� PLAN CHECK APPLICANT . ' k � � o •R
I hereby af4irm that 1 am exempt from the ContraUor's License � �• •u r`�L'
Law for the following reason(Section 7031.5, 6usiness and NAME � , ��x
Professians Code): � �� - `
❑ I, as owner of ihe property, or my employees wilh A��RESS
' wages as iheir sole compensation,will do the wo�k ond � u v C �—rJ�n
the strutture is not infended or offered for sale(Sedion UTV TE�.NO.
7044,8usiness and Professions Code). OWNER
❑ I,as owner of ihe property,am exclusively controcting �L
wilh licensed mnlrodors to consfroct the project(Sec- qpDRESS +
tion 7044,B�siness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm rhat ihere is a constr�ction�ending agency for C�7Y N B� Ort Beaeh 92660TEi.Np714) 833-3600 ,
the performance of�he work for which this permit is issued COtvTRACTOR
(Set.3097,Civ.C.).
ADDRESS
lender's Name
CITV TEL NO.
Lender's Add�ess —
STATE LIC.
I tertify tfwt I hove read this application and stafe fhat the UCENSE NO. Cu55 —
- above informa�ion is mrrect.I agree to comply with all County
� ordinances and Stote laws�elaling to boilding consiruction,
and heieby aulhorize representatives of this County to enter - . .
u on the above-men�operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a=3-3-0�
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