HomeMy WebLinkAbout1646A (9) VlORKERS'CO'�!PENSATIONDEClA4ATiON APPLICATION FOR PERMIT �
I hereby affKm�hai I have a certificn�e of consent to selF
insure,or a cenificare oi workers'Compensaiion InSuroncr., �6A754C HEATING - VENTILATING - AIR CONDITIONING
or n cr.rlilir.d copy ihr.rcoi(Sec.3A00,Lr.b.C.) CE•BiB(REV.lOiB�� � ��
�cy No. Company
Cert�Fied cepy�s h��eby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wfih ihe cour+ty bu�lding inspec- FOR APPLICANT TO FILL IN ou�io'n� l r ��4��s. dQ .
lion deparimr.nl. ACC5ES5
(:RI!JT O�TYPE Oh'LY) �
Date Applicont IOCAtITY Q�77� �
NO. TVPE OF PF'�IAN�E CR ECU!o:".ENT !EE ��
CERTIFICATE OF EXEh",PTION FRO!.t WORKERS' ' n�naEST �� `�
CO".tFENSATION INSURANCE CeOSS Si.
(This soetion nud nof bo eomplafad if Ihe wo�k Involvad by �ASCR'rTICN U.'dIT,BTU U�51R'CI NO� FPOCt"[0 9V
1h�pormil Is for one hundred dollars(f100)or lets.) piq HANDLING UNIT,CF.1A +O rn ��R
I tcrtify th�t in Ihe performance of thr.work for which Ihis ��\
permi�is issued,I sholl nof employ any perzon in any monner COiLER,DTU
so as lo be.come subject to Ihe 1Ve kers'Compe.nsotion Laws. anropvni5 DnTE �NS�FCICR'S SIGN47V?E
DoIC A�PIi[ant CO".PRCSSC4,BTU ROUGH
NOTICE TO APPIICANT: I(, of�r.making �his Ccrli(icole of VENTIIATiOV SYSTEM FINAL �$7 V—��
Eze.mption, you should becomr, subjecl fo the. 6Vorkers'
Compensation provisions oi the Lobor Code,you musl forlh- EVnt�'J2ATIyE COOIER VALIDATION
wi:h comp!y i�h such provisions or Ihis pc�mil sl�nll �e
dCCmedrevOkC[�. y FURNACE: FAU_GRAVIT '
LICENSED CONTRACTORS DECLARnTION '/ FlOOe l3TU
I hemby ofhrm that I om licnnsed under provisions of Chap�er 9 � `:CED NiT_
�(commencing wiih Seciian 7000)ef Divis�on 3 of the Business HEATfR: yA� lO � .
ond Pro(BSSionS Ced=,and my lirrnsn is in Full iorte and e.l(ccl. )-
a
O
Licenxr Number Lic.Closs V
, N
Con�racior pofe �
H
❑ V
I am r..r.mpi undcr Sec.
Plan check fee a
B.RP.C.for ihis renson en
Dnre:
� PERMI7 ISSUING FEE S �d Q ?
Signa��re TOTAL FEE O O
01VNER-6URDE2 DECLnRaTION F'lAN CH[CK Ar'P�ICANT
I h�reby ef(irm that I r.m r,:empt Frem ihe Conrroctor's license ,
Low for thr.iollowin9 reoson(Sec��on 7031.5, Bus�ness and Na".f
�Pro� ssions Cede�:
I, as owner of thc prepe�ly, or my employcr.s wi�h ADC:F55
wng�s os�h��..ole compensn�ion,wi�l do�ti�wo�k a�d CI7Y TFI.n0. •=I �t7-6 r1
�he srruc�ur��s nor�niend^d er offered for sole(Sec��on
70a4,Bus�nr.ss and Professions Codr.). �
OV:h[R nQ / n ,���!1 ti i • • s .`a
❑ I,os owner of�he property,am erclusively controcting �� L�,�f(S/ 1J
with licr.nsr.d con�rnc�ers 10 cnnslrucl Ihr,projecl(Sec- ��`�'� � • •G C.�Q
tion 7044,�usinrss and Prr.(essions Code). �CDR�SS �/!�I S[,�p�/� _� i
CONSTRUCTION IENDING AGENCY �iTy � � TF� �O Jv� • ••G J J O c:
I hereby a!(irm tha�ihere is a construc��on lend�n���ency(or
fhr.perlarmonce ol ihe work for which�his permil is issued CONTrtn[iOF � � , � C 9,� �—��
(Sec.3097,Civ.C.J. .
• AD�RFSS r C' J
Lender's Name ,?
CITY TEL.h0.
Lrnder's Address �
I cerlify Ihnl I hnvr,rend this app�icalion and stnle Ihnt the LICENSE NO C1A55 .
above information is correci.I ngrer.io comply wi�h all Coun�y �
crd��ances ond Sto�c lows reln�in�io 6uilding cons!ruc�ion,
and hereby nuihorize represeniarives of+his County io en�cr
uqm the ob�=d"—riy far insp^ci�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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