HomeMy WebLinkAbout1451A iWORKERS'C�MPENSATION DECLARA710N APPLiCATtOPi FOR PERMIT �
I hereby aff'Km fhaf 1 have o certificote of tonsent to self �
insura,or a certifiwte of Workers'Compenam�on�osura�ca, ��� -- -- HfATING - VENTILATING - AIR CONDITIONINC
ora certified copy thereof(Sec.3800,Lab.C.) �E-818�REV.10/81) � � ���- � � -
P❑ality No. Company �
Cenified copy is hera6y furnished. COUNTY OF LOS ANGECES BUlLD{NG AND SAFETV�,��{
� Certified copy is filed with the county building insper FOR APPLICANT TO FILL IN eU1lDING
tion depar�menf. ADDRE55 �(7 — � �
(PRINT OR iVPE ONLV)
Date Applicant LOCALIiY ��'�'�
NO. TYPE OF APPIIANCE Olt EOUIPMENT FEE
CERT1fICATE OF EXEMPTION FROM WORKERS' NEAREST //�(
COMPENSATION INSURANCE CROSS ST. (�*Cl�IU ^ �h ,,,��j �/C
(Thl�utfion nwd not 6�aomplafod if tAa work Mvolvad by pB50RPTION UNIT,BTU OISTRICT ND. VROCESSED BY
tM parmlf Is For ana hundrod dollon(5100)or loss.) qIR HANDIING UNIT,CFM �
I certify thot i�the performance of the work for which�this
permit is issued,I shall not employ any person in any mannar
so as to become subject to the Workers'Compensotion laws. �i�R,eTu APPROVALS DAiE INSPECIOR'S SIGNATURE
� COMPftE5502,BTU � ��-� �� ROUGH
Dote opplicant .. _.__.
NOTICE TO APPLICANT: If, after making this Certificate of VEN7ItATION �� 6 D U O FlNAL -fa
Exemption, you sheuld become subjecf to the Workers' �
Compenwtion pravisions of the Labor Code,you mvst farth- ev,avoRnnve COIXee. VAIIDATION
with compVy with svch provisivns or-this permil ehal! 6e
deemed rervked. �' � � ' FURNACE: FAU GRAVITY �1 ��
�LICENSED CONTRACTORS DECLARATION FLOOR BTU !/
I hereby offirm fhat I am licensed under prnvisioni of Chapter 4 SUSPENOED UNIT_ -
HEAiER� wA��
-(commencing with$ectian 7000)of Division 3 of the B�si�eu
and Professiona Eode,and my licansa is in full force und effect. �
/� d
License Number�Z�S Z � lic.Class 'S �a y
I,, , �
Contractor '✓��"' Date ��5�$3 0
r
❑ I am exempt onder Sec. ;_� L; � '
Plen check fee �' `' a
B.&P.C.for this reason � � � � ��; Z
PERhM1IT ISSUING FEE$ 0 � '
��� �ate:
Signature cw.., TOTAL FEE � i a � '.,''� � ,
OWNER-BUILDER DECLARATION claN cHecK naaL�UNF -
� r Y . -_
1 hereby affirm thot I am exempt from rhe Contracfor's License � -�
Low for the following reason(Section 7031.5, B�siness and NAME �
Professions Code):
❑ I, as ownar of the property, o� my employees with ADDRE55 •
wages as their sole compensation,will do the work and � •�— � ���
the struct�re is not intended or offered for sale(Section CIN tEt.NO.
7044,6usineu and Professions Code�. �
OWNER �
❑ I,as owner of the property,am exclusively confracting ,
� wi�h licensed comractors to construct the p�ojed(Sec- '���
tion 7044,Business and Professions Code). a��RESS
CONSiRUCTION LENDING AGENCY c�tv TEL NO.
I hereby affirm that ihere is a construction lending agency for �
the performance of ihe work for which this permil is issued � CONTRACTOR �,�
(Sec.3097,Civ.C.). .
ADDRESS ry � n ��� " � �
. Lender's Name '
CITY � � TEL.NO. �6 c �
Lender's Addrezs (� /� �
I cerfify ihnt I have read this application and state thal the LICENSE NO. Q� C A55 l..`�Q .
above information is mrrect.I agree to comply wilh atl County
ordinances ond State laws relaling to building construction, .
and heraby authariee representatives of ihis County to enter �
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a��- ��5`g3
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