HomeMy WebLinkAbout1450A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
I hereby affirm Ihot I Fwve a certificme of consent to self .
insure,or o certifimte.of Workers'Compensation i�s�,o��e, ���� -HEATING - VENTILATING - AIR CONDITIONING
or a cerrified copy thereof(Sec.3800,lab.C.) CE-618�REV.10�81) � �
� Qcy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY����S
� Cartified copy is here6y furnished.
� CertifieP copy is filed with the county boilding inspec- pQR APPLICANT TO FILL IN BUaDiNG /��l�^� �l I
fiOn de a11men1. (PRINT OR TYPE ONLY) P.DDRE$$ � -/
Date Applicanl L���T�" � �ti v f`
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERT�FICATE OF E%EMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE Cti055 Si. �(`�CJ ^�/y��,�, � 13�
(ihl�section nwd not ba wmpl�Nd if Iha work Inrolrad by ABSORPTION UNIT,BTU oisre�tt tio- vaowss�o ar
f tho pQrmH is ior ona hundrad doUars(S1Y�)or lasa.}
AIR HANDLING UNIT,CFM �
� I<ertify rhat in the performance of the work for which this
permit is issued,1 shall not amploy any person in any manner gOILER,B7U
w as to become subject to the Workers'Compensation Lows. navrtovnis DA7E NSPFCIOR'S SIGNATURE
Da�e Applicanf COMPRESSOR,BTU �� ++ Q �� ROUGH
� v J FINAL l
NOT�CE TO APPLICANT: If, after making this Certificate of VENiILATION 5 � � /�.ID
Exemption, you should become subject to �he Workers'
Compensation provisions of the Lobor Code,you m�st forth-_ EVAPORAT�vE COOtEB VALIDATION
with comply with such provisions or this permit shall 6e
deemed revokad. FURNACE FAII GRAVRY AU
LICENSED CONTRACTORS DECLARATION .Z FLOOR BTU D �
1 hereby offirm that i am licensed under prorisions of Chapter 9 HEATER� SUSPEN�ED UNIT_
-�commencing with Section 7000)of Division 3 of ihe 6usiness ' � WA«
ond Professions Code,and my litense is in full fwce and effect �
License N�mber 7����li[.Class�_ �
, V
Contracto��)�_ ��r po1e ������ �r
❑ I om exempr under Sec. W
Plan check fee o.
B.Bv.C.for this reaion ' pERM1T ISSUING FEE S � z
D e:
Signature �/����i TOTAL FEE O
OWNER-BUILDER DEQARATION P�AN CHECK AGVLiCANi . . �- � . .. .
I hereby offirm tha�I am eYempt trom rhe Conirocror's License , � ,- • • �� +�'
law for Ihe following reason�Sedion 7031.5, Business and nlaME �
Professions Code): I • % i� `;��
❑ I, as owner of the properiy, or my employees wiih �RE55 � � •_
woges as their sole mmpensafion,wiil do the work and . � ° ° � �- �^
the strucwre is not intended or offered for sale(Section ��T� - TEt.No.
7044,B�siness and Professions Code). :.'::���—'
OWNER � �
❑ I,as owner of ihe property,am exclusively coniracling
with licensed contractors to construd the project(Seo- 1i�'«
tion 7044,Business and Professions Code). ADDRESS .
CONSTRUCTION LENDING AGENCY Ciiv TEt.No.
1 hereby affirm that there is a construction lending agency for
the performonce of the work for which this permit is iss�ed � CONTRACTOR� � � C ,
(Sec.3097,Civ.C.). d �"'' . . .
ADDRE55 / - - --�� � :....
Lender's Name � � �
CITY 1��� . �. 7E�_NO. r��p 5�3
Lender's Addtess
STATE c e--� LIC. C C -`
� I certify 1ho1 1 have read this applicotion ond state that ihe LICENSE NO. ,�f�[7.� f CLA55 �V
obove informotion is correct.I ogree lo comply with all County
ordinances and Sta�e law:relating lo building construction,
and hereby authorize representati�es of�his CouNy ro enter .
upon the obove-mentioned property for inspettion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Ck.a„L,� �-�5�g 3
Signolure of Applicon�or Agent Date
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