HomeMy WebLinkAbout0789A � , .. � \'JORKfRS'CO"r�ENSATION�'CLARATION / �qppLICATION FOR PERMIT 1 hereby ef(irm ttioi I hovr,a cenifico��of consem to self � inc�rc,or o trrtilicoio of 1vo�k���Comrt!nsn�ion i�5��a�«, HEATING - VENTILATING - AIR CONDITIONING or a cerlili=d cr.py Ihrrenf($ec.3A00,lob.C.) CCA3A10�G,V.10/81) O�Y N�� Company Cc���1�ed copy in he�eby fu���shed. COUNTY OF LOS ANGELES - BUILDING AND SAfE7Y � Cer�ifled copy Is flled wirh the covnry huildfng insp�c• FOR APPLICANT TO FILL IN eui�e!vG � � tion departmenl. � (PB'�T C4 TYP:pNLV) ApCRE55 �� S ,s ef J Dat� Appl�cont �ocnliiv / D NO. TYPE OF AP?�IANCF OR FOUI�S�FNT FFE 6 CERTIFICATE CF EXEIdPTlO'J Fn0".1 1V02KER5' r:EavEST CO"'•�ENSATICN INSURAhCE CROSS ST. ACSCpF110N UNIT,pTU (This socflon naed no}6e complefed i!fhe work inrolred by e:i��u�o caoav.ro er the permille For one h�ndred dollan(SI00)or less.) I cer1�(y thot in th�p�riorman��ef Ihr.v�ork for�vhich this AI7 HANDLI::G UNIT,CFM /Q �rtrmit is iss�ed,I sholi not er�ploy any p�rson in any monner so ns to become subj�c��o thr,�Yo�kr.rs'Camrrns�liorllnws. FOItFR,Bill�p d 0 �V � an;q��qi5 GeiE � S�FC1C�'S�iGN<iII�F ✓1 p�� \ CO:'i'RFSSC4,8TU 40UGH �nlicont__ , // �� NOTI i � �I'ANT: If, oflCr mOking Ihis Cr.rtili .r. nf VCNTILATICN S�STCM FINAL /��� ' �'S� Exe .p'ion, you should L•ecome subjr.0 to the Workcrs' Comrensalinn Arovisions of Ihn Lcbor Code,you mus�for�h- EVAPG7AiIVE COOICR VALIDATION i!h cemply with such provisiens er ih;s pe�mii shall b^ d��mpcl revok��1. , FU?YACE: FAU_GQAVITY �LICENSED CONTRACTORS CFCIARATION FLOOZ BTU I hereby ofi�rm+hot I cm licenscd under prov�s�ons of Chc��cr 9 SUSMNCED UN!T_ I+FATF�: WALL �tomm�ncinc�wi�h Set�ion 7000)01 Divisinn 3 of�h�Busincss and Profess�ons Cod^,and my lic=nse is in full(orce and effett. � { Y J a License Number Lic.Cl�ss � , K Canrrn:�or pol? � 0 r ❑ I nm rxempl und�•c=c. `rJ 7�'�'} a Plan check fee �.BP.C.fcr th�s rcosen PERMIT ISSUING FEE S J J S't) .• • • • •a Z Da'e: 5�gnew�e TOTAL FEE ,�j �� I • a�Q 5 Q OWNER�OUIICER DECLARATIO'd RAN CNECK A�'LiC�NT � e V n j�� 1 hereby nlfirm!hat I ari e.empt from 1hr,Conlroctor's licensr, ��1 � Ln•.v for th�{allowing rcason(Seclion 7031.5, L�usincss and N4.'E� h �/ /� r•�� , �� � ,_�'� Prn<,..<ions Cadv); ��+----�'�L_y!� ❑ I, as owner ol ih_ o � o� m em lo aDD�[55 /� ��� n V 5� =pr prr y. Y P v^^s with �f � 1_% l og�s as�he�r solc com�anso�ion.will do thr,wo�k o�d CiTV s'rudu•c is no�In'ended cr o�lered ior sote(Sed�on 7044,6usiness and Prof�ssions Code). OW!�'ER �� I,os owncr r,F fhc�rep�rty,�m r.xclusivrly con�rotlin9 w��h Gcens�d[OIIhOCfClS�O COI15��UCI IF1C projec�(cec- �'n�� licn 704A,Busi�ess nnd Pro!rssio�s Code). ADC7E55 _ CCNSTRUCTION LENDING AGENCY CITY Tft.NO. � � I h�reby offirm tha��hero is a cens�r�tiion Iendin�j nc�r.ncy(or , � �he perfermancr.of ihe work fnr which this permii IS ISSIIP(I COviRnCiO� (Scc.3097.Civ.C.). ' . PDDGE55 len�7rti s Nnme � CITY TFI.ND. lender's Address � STaiE UC. I cr.�iify thn�1 hove rr.od ihis aaplica'ion and s�a!e ihni�he LiC[h5E n0. CLa55 obov�info�mo'ion is corrrcf.I o��c^�o comply wi!h oll Couniy crd�nonces ond S�a'c lows r^Iniing to buildlnc�const.uciion, nnd hcreby ao�hori:e represeni�iives of�his County io cnter upon thc c�ovc�me�lio�r,�!(�ro�crly fo���r---yyyin5pc:��o�p�r eses. 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