HomeMy WebLinkAbout1394A WORKERS'COMPENSATION�ECIARATION APPLICATIOM FOR PERMIT �
I hereby affirm that I hava a certifica�e of consent ro self
insure,or a certificate of Workers'Compensation Insurance, ���� HEATING - VENTILATING - AIR CONDITIONING .
or a certified�copy thereoi(5ec.3800,Lab.C.)
iCE-818�REV.10/BI)
� P❑olicy No. Company
Certif�ed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wifh fhe counly building inspec- FOR APPLICAN7 YO Flll IN BUIL�ING r� p
, tion deportmenl. (PRINT OR TYPE ONIY) , ADDRE55 41� VNN�'� l�/t'
Dafe Applicant IOCAIITY �7���.yv�6/�(L ���
` NO. TYPE DF APCLIANCE OR EQUIPMENT FEE
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEARE57 � �� � ,
- COMPENSATION INSURANCE CRO55 ST. 'i
. (Thls weflon nNd noT 6a eomp{ofod if tho work involvad hy ABSORPTION UNIT,BTU oisreicr rvq. vrsocesseo ev 'ii
tho parmif is lor uew hundrod dollare(5100)or less.) �� '
� I cerfify that in the performonce of fhe work for which this A�R HANDLING UNIT,CFM
permit is issued,I shall not employ any person in any man�e� � `')� Q�Q � I
. so os ta become subjacr to the Wor ers'Compens ti n laws. BOitER,e7u a arvaovn�s oare iN FCTOWS SIGNATURE
'��/t+�/J . v COMPRESSOR;9iU ROUGH
' Dutei��p..p�PPlicanl .
NOTICE�TO ApPLICANT: If, of r aking this Ce itimte VENTILATION SYSTEM F�NA� I"j N.� ��.�v
� Exempfion, you should bec subject to t e Workars' -�
Compenwtion provisions of r labor Code,you musf forth- EVAPORATIYE COOLER VALIDATION
. with comply with such provisions or this permit shall be .
deemed revOkEd. FURNACE: FAU�_GRAVITY
' LICENSED CONTRACTORS DECLARATION FLOOR eiu
I hereby affi�m thm I om licensed�nder provisions of Chapter 9 HEATER: SUSPENDED uNii_ �
' '(commencing with Section 7000)of Division 3 of the Business ` WA��
� and Rofessions Code,and my�icense is in fvll force and effect. �'
O.
0
� License Numbar - Lic.Class � U
OC
Contmctor Date 0
� �139,4A ~
t am esempt under Sec. �
Plan check fee �� �� � �� �
B.&P.C.for this reason
PERMIT ISSUING FEE$ �
� Date: /� � ++v Q,J�Q i
Si nature TOTAI FfE O �2? _ �
9 •• •5Q50�
- OWNER-BUIL�ER DECLARATION PIAN CHECK APPI�CANT �.�r
't I hereby affirm ihot t am e:empi from the CoMmcror's litense . � �����8(�
Law for the following reason�Sec�ion 7031.5, B�siness and NAME. �� . _ .
�� Professions�Code�: � � �� - � � - �
❑ I, as owner of Ihe property, or my employees with ADDRE55 —
wages as their sole compensation,wiltdb iha wotk ond ��TY .r�-� . 7EL-�m.. r.�..�� ..
the structure is not intended or offered fw sale(Section � �
7044,Business and Professions Code). OWNER �� �,f �� /
❑ �,as owner of the property,om exclusively contrading �v�`
with licensed conhactors to construtt the project�Sec- N'p'�� �� �L' f7O�
tion 7044,Business and Professions Code).�- � ADDRE55 � 1//�/Y
CONSTRUCTION LENDING AGENCY Giv ��y ��-y�.. iei.NO. 1��I�6�/
I herehy affirm that there is a construction lending agency far , �
the performance of the wark for which this permil is issued ' COMRACTOR� �f����� � ��� - � � '
(Sec.3097,Civ.C.). � .
ADDRE55 � ��/d�
Lendei s Name
C�TY � tEt.NO.
Lender's Address
STATE LIC.
I certify that I have read�his applimtion and state that the LICENSE NO. - CLA55
above information is co�rect.I agree to comply with all Couniy
ardinances and State laws re�ating to building construction, � �
and heraby authorize representptives of ihis Counly to enter � -
up n tha bove-men i�o ed property for insp ction purposes. SEE REVERSE FOR EXPLANA70RY LANGUAGE
� qnalore of Applica t or qenl . . Dote
}a" � I
V +� + '
"0 � N � Q� C
.-�� ��:n v.� �� D ; 1; .
V C pi y L C O 6 �.
�� y� C D N ve y C C-C ' m p U a'` � ' " "
y.c ' 'N � n.�- 6, .C O o� � 6 �1 � � O �' � � '�' � .
y 6i L,. d p � 4.� � p m �n'�Ol L ^'m L u�
� ,.;��, a 3 °.° � ° � o � 0.�°v aarn u �'- °' o °' � '
° i�LaM '" „ �" �� �s 3 �y � � � � o �c m = v3y `a, . �
m �- � o i
o� >� am o��c-o ° � > �o c3 �°' - " o � oU c�= . ' I
C C G'-O m p��n tJ �'�p � d� Q 47 7i O N O G.� O v D �y . I '
0 0 o y u 'y E � E ° �o ro°o °c a� o� n i° o ° ��
c '
�' m m U � a� o.o c,°� '�^= ��N ° �_F o i-m ''i' a c '"o-�u c 1,
v N ._ � �- ` C � -.d- O v ' 1
O � �O_ � � p�P m � T� O +-O.Oin T� u 1w �O n y � p O D t C� tl� 6
N_ a
i a a ` . '" � o ��. c m E e: �n.w � m.t d �°' o ,n o � � 1�
G- a Q n' o £� a� 9-Q. a c � "a � �,� s ��" m�s � a m o ° o, � N ,,� ,�
►�i� E rn;..-,°- o o.?,u ° m o o c�.� c >-c 'o � 'o n �d `"v o-s-+. � 's � �
� K �z' �� � � � �' c. � S � � d °-°'a-evs o c � c 3 E �� �- ,a ;
� �''3 �� ` a � a3 a � �o »�. o c °,� fl-> d °-- �y 3 °�' - � .. � � �c ; `e�
W � r.� m � �"� m a� u� � E ° n, � 3 E N; � � o �a X v � a C
p � Y o ° �.° c °' '-� m^a°Q � °c '�.'n o �`°c�� ���v c'�•o c �' a" E o O
' - a N o?c u cC' L-o o_ . o N ,�°�, d ._ ° =�� � �3 n„o t dS ! L]
d� a � m _ `' u= u o c��-.>o �`° �ro �z, d '�'-° � o,o .J� s u o �
�' s o 'E�n:-�� � o o a n'u o o �� y •� L � > �� u �, L �s �
� E° �' mcos.� o�-o7.ov� -`o �,.c ,Yc ac aso ; � ..-
Z � c °'° m °r' o m� ° �i.�� s � � o � a> E �� _
3 �ooca � �+oov .t"'. o � �'o; �c
� r� v, m p.v+ - c� M.�O S �, . .
N � C � � � N O d N�o �� . ..
Su-� � O��£V✓i
J� �
'
'
!
�
1
'
` , '
tN I
� 1
1 �
i
� '1
�
W
�
2
�
O
�+
N
. . �
�