HomeMy WebLinkAbout0640A (4) WORKERS'COMPENSATION DECLARATION APPLICATiON FOR PERMIT �
I hereby affirm that I have a cartificafe of tonsen�to self
insure,or a certifimta of Workers'Compensation i�5��a��e, ���� - HEATING - VENTILATING - AIR CONDITIONING
oi a�f rfifie copy thereof(5 C.�Q�,Lob./C�.) � /' ��. CE-818�REV.�OiBt
O.Xwa 9� �5oi����� Q/`W C�vG! ) . . ..._ _. . . . ..
�f
Certified copy is he�eby fu�nished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county uildi inspec- FOR APPLICANT TO FILL IN BUIL�ING �
tion department (PRINT OR TYPE ONLV) ADORESS
Date ��/~ Applicanf LOCALITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT PEE
CERTIfICATE OF EXEMVTION fROM KERS' NEARE57
COMPENSATION INSURANC � CROSS ST.
(This section nssd nol b�eornplNed if}ha work involved 6y . ABSORPTION UNIT,BTU p15TRiCi NO. VROCESSED 8Y
tha permN is for on�hundrod dollan(5100)or len.) �d
1 certify that in�he performance of the work far wh�ch th�s �+IR HANDLING UNIT,CPM -
permit is issued.I shall not employ any person in any manner
so as fo 6ecome su6ject to the Workers'Compensotion Laws. BO�IER,BTU nwqpva�s oAtE iNs R'S SIGNATIJRE
�f �V?T� 3.O�d1/a
Date epplicont �^' COMPRESSOR,BTU �� � ROUGH
NOTICE TO APPIICANT: If, ofter making this Certificate,of VEMILAT�pN SVSTEM FiNAL
Exemption, you should become svbject to 1he Workers'
Compensation provisions of 1he la6or Code,you must forfh- EVAPORATIVE COIXER yA �� TION
with comply with such provisions or �his permit shall be
deemed revoked. q FURNACE: FAU RA�Y �O
IICENSE�CONTRACTORS DECLARATIDN N FLooR eiU
! I here6y affirm ihat I am�icensed under provisions of Choplar 9 HEATER: SUSPEIVDED- UNIT_
4 �(commencing with Sedion 7000)of Division 3 of the Business WA��
ond Professions Code,and my license is in fvli force and effect. A _/ � � �r � � - �
LJ,�� O� �t^"G[/6�'
License Number�2LIL�.—Lic Class� V
E �
�a'�icr�4 T �,��,_c�� c D 6 4,C A �
cor,va�ro, oa,e_�
�
❑ I om exemp�under Sec #• • • • •.II 6
Plan check fee ( • •�[.5 D '^
8.8P.C.for this reoson� Z
PERMIT ISSUING FEE� J
Dare: • • •9�.5��
5gnoture iOTAL FEE ,2
OWNER-6UILDER DECLARATION FIAN CHECK APPLIfANT r—�� C Pi,C�—Fi S
I hereby affirm Ihal I om exempt 4rom the Coniractor's License �
Law for the following reason(Sedion 7031.5, Business and NAME �
Professions Code�:
❑ I, as owner of the property, or my employees with ADORESS �--���
wages as iheir sole compensation,will do the work and .
the slrut�ure is nor intended or offered for sale(Section �ITY ..s—�_. TEL.NO. ��
7044,Business ond Professions Code). �
❑ OWNER
i,as owner af the property,am exclusivaly contracting
wilh licensed contractors to construct the project(Sec- MAII Q �
tion 7044,8usiness and Professions Code). ADORESS
CONSTRUCTION LENDING AGENCY cm -hi.No.
I hereby affirm ihat�here is o construction lending agency for
the perfoimance of ihe work for which this permit is issued CONTRaCTOR
(Sec 3097,Civ.C.). .
ADDRESS e
Lender's Nome
CIiY n TEL.NO. �
Lender's Address �e
STATE LIC.
I certify tha�I have read�his ppplimtion ond state that ihe L�CENSE t�0. CIASS - �
above information is correct.I agree to comply wirh all County �
ordinances and State laws relating fo building construction, �
and hereby auth �e represematives of�his Counry fo enler ,
upon the er#ioned pro erty for inspeqctian purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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