HomeMy WebLinkAbout0892A (6) WORKERS'COMPENSATION DECLARATION � /yPPLICATION FOR PERMIT � �
I hereby affkm ihat I have a certificate of consent to seif
insure,or a certifitare of Workers'Compensor�on Inswance, �bA�C HEATING - VENTILATING - AIR CONDITlONING
or a certified copy ihereof(Sec.3800,Lab.C.)
� CE-818(REV.10/81)
P❑olity No. Company .
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
•� Ce�tified copy is filed with the county building inspac- FOR APPLICANi TO FILL(N BU�tDING y
fion deparlmem. (PRINT OR TYPE ONLY) ADDRESS
Oafe Applicanf ��A��N .�//� yy �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE .
CERTIFICATE OF E%EMPTION FROM WORKERS' .. NEAREST
COMPENSATION INSURANCE cRoss 57. /rL� O
(Thla sxlion n�ad not be wmplefed if fhe work Inrolvod b� ABSORPTION UNIT,6TU DISTRICT NO, PROCESSED BY
tha pormll L For ona hundrod dollan(it00)or lass.f �
I certify that in the performonce of the work for which Ihis AIR HANDIING UNIT,CFM 1/� O
permit is issued,i shali not employ ony person in ony manner �v
so as to 6ecome subject to tha Workers'Compensoiion Lows. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNA7URE
7� Dole Appli[ont COMPRESSOR,B7U ROUGH �8• .�ff�
1�NOTICE TO APPLICANT: If, a+te� making this Certificate of vENTItAriON SvSTEM fINAt k� �
Exemption, you sho�id become subje�t to the Workers' ~
Compensation provisions of tha Lobor Code,yo�must forth- EVAPORATIVE COOLER VAL{DATION
wish comply with such provisions�or this permit�shalf be
deemed revoked. FURNACE: FAU_GRAVITY .
LICENSED CONTRACTORS DECLARATION FlOOR � BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEA7ER: SUSPENDE� UNIT_
�(commencing wilh Senian 7000)of�Division 3 of ihe 8usiness �'`�P'u
and Professians Code,and my license is in full force and effect. y
,O d 0.
License Number �9 Lic.Ciass �� {� , U
I o r� ` 1 0C
Controcto �o�e � / �/ �F
v
1 am ezempt under Sec. p�on check fee Q-
B.BP.C.for this reason �
PERMIT ISSUING FfE S �
Date: .
Signaiure TOTAL PEE `�
OWNER-BUIL�ER�ECLARATION PLAN CHECK APPL�CANT .
I hereby aftirm that I am exempt from the Contractor's License � -
Law for the following reason(Section 7031.5, Business and Ntv.nE '
Professions Code): ,
❑ I, as owner of the property, ar my employees with aDDRE55
wages as their sole compensotion,will do the wark and CtTY� 1EL n10.
ihe siructure is not intended or offered for sale(Sedion z U��!.r A
7044,8usiness and Professions Code). OWNER �
U fL�lt /�L ". .. . .g
❑ 1,as owner of the property,om exclusively contrading � . -
with�icensed�coMractors to construct the projed(Sec- A�DRE55 .y � Q l �, � '' •2 C,L.�i
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ��7y _IEL Plp, • " '�G G J��
I hereby affirm thal there is a construction lending agency for � '�H�
the performance of the work for which�his pe�mit is issued �aNTRACTOR�y��� � Q&� �—8 7
(Sec.3097,Civ.C.). �'��'�
ADDRESS � ��±5 � � � . �
Lender's Name p� �
„ CITY �1���� � TEL.NO.�I��pO 00 �
Lender's Address �
STATE �a LIC.
I certify Ihal I have read fhis applimtion and sfate ihal the uCENSE NO. �- / / C1A55 �' .
above infwmo�ion is correct I ogree b comply with all County . �
ordinancas ond Smte laws rela�ing to 6uilding construction,
and hereby authorize re resentotives of this County lo enter . � �
upon the above-m f�'rt inspection urp s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaWre af cont or Agent � � . I
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