HomeMy WebLinkAbout1728A (17) WORKERS'COMPENSATION DECLARAiION /
I hereliy affirm Ihol I have a terlificate of consent to sel( APPLICATION FOR PERMIT /
insure,or a certilitaie of Workers'Compensation Insurance, �6n76aC HEATING =VENTILATING - AIR CONDITIONING �
o, r p C�tifje�cop�reof 5 3B ,Lob.C BIB eEv.10/81) � - � � \
.�`ofiry�No�� � r�n � �3.�. . � \
� Certified copy�s heieby furnished. . , COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Ce�lified copy I5 filed with Ihe count uil tny JJJ' P c- - FOR APPLICANT TO FILL IN �- _ eunowc ^ �-
fion�pqrfm nf,/ , �� (PRINT OR TYPE ONLY� ADDRE55 ��O�CG
/n (A •
�ate Z� 4�Applitanl LOCnIiT �
NO. NPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFI ATE OF EXEMP FROM WORI(ERS' NEnaEST •
COMPENSATI INSURANCE Ce055 ST.
(Thf�sacffan nood not bo tomplatad tf 1he work Involvod by A8$ORGTION UNIT,BTII DISiRiCE NO. YROCESSED BY
fha pormif Is Io�one hundrad dollars(SIQO)or lesz.) AIR HANDIING UNIT,CFM /v
I certify that in the performonce of Ihe work for which this C
pe�mit ts Iss�ed,I sholi nol emplay any person In ony manner BOiIER,BTU
so os�o become subject to�he Workeri Compehsalion Lavn. avvxovn�5 DATE MSCECTOR'S S�GNAiURE
/ O
Date App�i�o�� COMPRESSOR,BTU.�'��� �6 ROUGH
NOTICE TO APPLICAN7: If, after making this Certifica�e of VENTILATION SVSTEM FINAL
Evemp�ion, yo� should become subject �o fhe Workers'
Compensotion provisions of the Labor Code,yo�must forih- EVAPORATIVE COOLER � VALIDATION
with comply with s�th provisions or Ihis permil sholl be ,
' deemedlevOkBd. FURNACE: FAU�GRAVITV
LICENSED CONTRACTORS DEQARATION FIOOR BTU �
I here6y effirm that I am licensed under provisions o(Chop�er 9 HEnTER; SU57ENDED UNIT_
�(tommenting wilh$edion 7000)of Division 3 of the Bosiness ' WA«
and Rafessions Code,ond my license is in full force and effecL - � >-
2 �rL OvT 3 S'c� a .
,licensa Number � t,Class � � - � - -- �
7 Z6 � V
Coonoc�or '� �me z� 7 2 8 A 0 �
#. . . . .g c`'i
❑ I exempl under Sec. � . � W
8.8P.C.for�hfs reason� P�an check fee � - I • •2 Q.0� N
Daie:
PERMIT ISSUING FEE S O ;.2���� 2
5�9oaw�a TOTAL FEE � fla 0 7.2 9=8 5
� OWNER-BUILDER DECLARATION PLA CK AVMICANT
I hereby aHirm tho�I om e*empt from ihe CoNroUor's license � .
Law for fhe following reason(Seclion 7031.5,Business and NAME � .
Professions Code):
� ADDRE55
I, os owner of the property, or my empioyees wilh � � �
wn�es ns ihefr enle cnm�ensofnn w�ll de rhP wnrk or+d . pTv TEL NO. � � . lI,.
the structure is not infended or offered for sole(Section 1 ,"l.
7044,8usiness ond Proiessions Code). . /�.�� r '
OWNER � ���!�+/UI� �
❑ I,as owner of Ihe properry,am ezclusively tontratting • �
wiih licensed contractors to construct the project(Sec- '�'��� ^� 1
tion 70d4,Business and Professions Code). ADDRE55 U?�Q Z �i�j(f��- �/11 .
CONSTRUCTION LENDING AGENCY CIN � � TEL.NO. �O�r �
I hereby affirm�hot ihere is a conshuction lending ogency for
the performance of 1he work for which�his permit is iss�ed CONTRACT ,` , �
(Sec.3097,Civ.C.). �� N ' ,
ADDRE55 ' (,��� , �, ' _ _ .- �r � .
Lender's Name " -
� CIN. l� . //LI� TEL.NC� _ 6
Lender's Address " - - -
STATE 2 ❑C. �, l
I certify ihat I have read ihis applicatian and s�ate that the LICENSE NO. ���D.J -CLA55 - ""�GlJ- . -
above iniormaiion is mrrect I agree ro comply with ail County ��� � � � -� /
ordinanres and S�ate laws reloiing to building construttion, _ _ . . .
ond her y ao onz�/r�epresentarives of rhis Counry ro enter � -- � '--- - ' � " " -. � -� - � --� - ,
u + obo�e�-mer�1�6 _d�prop.rty tor ins e iion pu��ios� SEE REVERSE FOR EXPLANATORY LANGUACE �
C � G yh -( �
5' naNre of Appliconi or Agenr Da� - � - - ' - ' —. .. . .
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