HomeMy WebLinkAbout0881A (4) WORKERS'COMPENSATION DECLARATION qpp��CATION FOR PERMIT �
I here6y affirrtyfhat I have a certificate of consent to self
ins�re,or a certificate of workers'Compensation Insurance, ��� HEATING - VENTILATING • AIR CONDITIONINC
or a certified copy ihereof(Sec.3800,Lab.C.) CE•81B(REV.10/81�
P❑olfcy No. Company
Certified copy is hereby Eurnished. COUN7Y OF l05 ANGELES BUILDING AND SAFETY
� Certified copy is filed wi�h rhe counfy 6uilding inspec- FQR/�PP���ANT TO FILL IN BUIIDING
tion deparlment. ADDRESS �` �` ,�jf/��
(PRINT OR TYPE ONLY}
Dole Applicpnl NO. TVPE OF APPLIANCE OR EQUIPMENT FEE L«ALIiY �0�� '�-
CERTlFICATE OF EXEMPTION FROM WORKERS' NEaae51 `� ���
COMPENSATION INSURANCE cR055 57.
(Thia saefion n�ad nof Iw complafod if fha work inrolved by E+B�RPT�ON UNIT,BTU oISTRiCT NO. rrspCE55ED BY
fho porm(f is for ona hundrad do{lorc(s100)or lass.) AIR HANDLIPIG UNIT,CFM
I tertify tfat in the performance of the work for which this 'O 1(�/� ��
permit is issued,1 shall not employ any person in ony man�er �` \
} SO OS f0 bBc me s�bject�o the Workers'Compensa�ion�aws. �ILER,BTU OO qiPROVAtS pAiF INSPECTOR'S SIGNAiURE
/ Ddle b� pplican(� 'G•vF• COMPRESSOR,BTU RWGH
NOiI E TO APPLICANT: If, after making this ertificate of VENiIIATION SYSTEM FlNAL
Ezemption, you should become subject to the Workers'
Compenwtion provisions of the laba Code,you must for�h- ev.4cONqnve COOiEa VACIDATIQN
with tomply wifh suth provisions or this parmit shall be
deemed revoked. ' Ft1RNACE� FAU—GRAVITY
LICENSED CON7RACTORS DECIARATiON ROOR 6TU
1 hereby uffirm tFwt I am licensed under provisions of Chapter 9 �A�R. SUSPEtdDED UNii_
�(commencing with Section 7000}ot Division 3 of ihe Business � '�✓A��
and Prafessions Code,and my licensq is in full'forte ond effed. - � y
�I d
� 1..������� �— C
� ticenseNumber �it.C�ass . V
Coniractor Date �
0
❑ t am exampt under Sec. G�.Sy�yF3 G�s��� �W�.m y�,`VY�� w
Plan check fee
B.BP.C.for this reason � � Z
! PERMIT ISSUING FEE S �Q Sa a�, �.��� Z—'��
Date:
j Signature TOTA!FEE
� OWNER-BUILDER OEfLARATION � Pl/+N CHECK APPLICANT '
, I here6y affirm that I am e�empt from the Controcfor's License �
' Law for the following reason (Sectibn 7031.5, Business and nl,ah�E �� � - -
��� P�ro�fessions Code): �O&�,� A
L7 I, as owner of ihe propeny, or my employees wilh pDDRE55� �'L � G����� .
wages as thair sole compensation,will do the work and #• • • • •a I
1he sfructvre is not in�ended or offered for sale(Sectian ��N / fj'/Q/r/,J TEL.NO��r-
7044,Business and Professions Code). . � • •2 Q Jr O
OWNER
❑ (,as owner of ihe proper�y,am exdusively coniracfing 2 a 5�_ '
with licensed confracrors to const�ucf Ihe projecl(Sec- App�� •.� • ci j
tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY ��TY rE�.No. 0 b 21-8 5
I hereby affirm thal there is a construcfion lending agency for ,
the performance of ihe work for which fhis permit is issued CONTRACTOR � .��1.•
(Sec.3097,Civ.C.).
aooREss
Lender's Name
CITY TEL.NO. '
Lender's Address
STATE LIC. -
I terlify Ihat I have reod this applimtion and stale thar the tICENSE NO. G1A55-
above information is corred.I agree to comply with all County . �
ordinances and S�ote laws relaling to building construction,
and hereby authorize represenlatives of fhis County to enfer ,
upon ihe above-mentioned properfy for inspection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
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