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HomeMy WebLinkAbout0991A WORKERS'COMPENSATION DECLARATION 76A3a4c HEATING ��VENTILATING - AIR � � � � � � I hereby affirm Ihat i hove a certificate of consent to self APPLICATION FOR P�RMIT� ��� � insure,or a<erfifimfe of Workers'Compenso'ion Insuronce, .....- Y ,. or a certified mpy thereof(Sec 3600,Lab.C.) " COMDITIOIYING CE 818IREV. ,0-81) � - P❑olicy No. Company . Certified mpy is he�e6y f�rnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY _..,. , ,. .. ..... ....... ,. .. . ...::. .,., � Certified copy is filed with the co�nty buildi�g inspeo FCIR APPLICANT TO FILL IN guroiNG tion depariment. AD�RE55 � � (PRINT OR TYPE ONIY; Date Appliconf LOCALiTY NO. TYPE OF APPtIANCE OR EQUIPMENT FEE � CERTIFICATE OP EXEMPTION FROM WORKERS' NEARES7 COI%PENSATION INSURRNCE CRO55 57. � ' - " � �" � (This secfion need not 6e complefed if fhe work involved by !BSORoT�OW UNI?,B7U oisTe�ct�o ceocesseo av 1he permif is for o�e handred dollars($100}or less.} AIR HANDLING UNIT,CFM i certify ihat in ihe performance af the work for which ihis 4>*�, � ' permit is issued,I shall not employ ony person in ony manner gpltER,BTU t` �� � so as to become subject ro the Worke�s'Compensotion LOWS. � APVRGVAlS onte iNsvecroa�s sicn�r.Yoae Dafe Applicant COMPRESSOR,BTU ROJGH , NOiICE TO APPLICANT: If, after making !his Certifimte of VENnLATION SYSTEM FiNA� ,� Exemption, you should 6ecome subjed to the Workers' Compensation provisions of the Lobor Code,you must forih- EVAPORATIYE COOLER VALIDATION with comply wifh such provisions or fhis permit shali be � deemed revoked. FURNACE FaU_GRAVI7Y LICENSED CONTRACTORS DECLARATION F�COR BTU I hereby affirm that I am licensed under provisions of Chap+er 9 SUSPENDED � UNIT_ '(commencing with Section 7000j of Division 3 of rhe Business HEATER� WALL } � ❑nd Professions Code,and my license is in full force and effeC. � � License Number Lic.Clpss � � � Coniractor Date } ❑ � I am ezempt under Sea Q Plan check fee a B.&P.C.for this reason- Q PERMIT ISSUING FEE$ m. oate: :r.4 n � Y04AL FEE • �`�.;"_:.�, w Signature - r OWNER-BUILDER DECLARA710N c�nN CHECK APPUCAIdT ��������`,'�'°i'�y',�,r�� . I hereby affirm ihat I om exempt from ihe Contrac'or's License �+ �- , Low for the following reason fSection 7031.5, Business ond NAME , .�,'a�R,--�• v;'rr Professions Code): X k,Q'F`".�';`y_;'a. ❑ I, os owner of ihe property, or my employees with !DDRE55 , . , � .� . -, � �?'-�. wages as their sole compensation,will do the work and �!'1'-'.IF.' '=�k- the sirucrure is not intended or offered for sale(Sectian C�7Y iEL NO. . , . ,�Nh�"'�:. , 704G,B�siness ond Professions Code?. ❑ �,a5 owner of the OW'NER property,am exclusively coniroc'ing MAIL ` with li<ensed mmractors ro construct the project(Seo- qooke55 fion 7044,Business ond Prafessions Code;. CONSiRUCTION LENDING AGENCY CITV 7E� NC. I hereby offirm that there is a mnstrudion lend�ng ogency for � "� the performpnce of the work for which'his permit is issued �ONieaC70�: � � - � ��� -�� �' -�� (Sec.30?7,Civ.C.). .. .,: �.. .. �. ._�.. :,.._...., �. . ADDkE55 Lender's Name CITY TFl ND Lender's Address I certit ihal I have read this a lication ond s±a�e that the STA?E � . LiC. Y PP LICENSE NO. .� C!A55 above informaiion is correct.I ogree to comply wilh oJl County ordinances and Stare laws rela'ing fo building construc�ion, � and hereby awhorize representatives of fhis County to enter upon the above-mentioned p�operty for inspec�ion purposes. 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