HomeMy WebLinkAbout3950AI 4
affirm that haveCOMPENSATIONDECLARATIONof consent APPLICATION FOR PERMITIherebyaffirmthatIhaveacertificateofconsenttoself
Iorinsure, Workers'Compensation
acertified copy thereof(Sec.38 0b. C.)
Insurance,
76A34C HEATING - VENTILATING - AIR CONDITIONING
CE_a 18(REV.10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec-
tion department. FOR APPLICANT TO FILL IN Ao eFSs'
PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT FF.FCERTIFICATEOFEXEMPTIONFROMWORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
This section need not be completed if the work involved by
ABSORPTION UNIT,BTU
pisTulcT NO. PRocesscp By
I the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
Ipermit is Issued,I shall not employ any person in any mannerfL.AsoastobeomesubjecttotheWorers' m ns n aws. BOILER,BTU - 7 j4. APPROVALS pATF INS CTOR'S SIONATIIHE
Date 'av V Applicant
11
n
COMPRESSOR,BTU ROUGH J,
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL c...1
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- FVAPORATNE COOLER VALIDATIONIwithcomplywithsuchprovisionsorthispermitshallbe
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FIOOR BTU—
hereby TUherebyaffirmthatIamlicensedunderprovisionsofChapter9SUSPENDEDUNIT
commencing with Section 7000)of Division 3 of the Business
HEATER:
W
and Professions Code,and my license is in full force and effect.
License Number Lie Class 1
td:
1 Contractor DateJ 9q O
1 am exempt under Sec.
2k w
i BAP.C.for this reason
Plan check fee a
6Date:
N
PERMIT ISSUING FEE$ t7 V I u '2 i)
Signature TOTAL FEE
OWNERBUILDERDECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason(Section 7031.5,Business and NAME
Profeis Code): 1
I •'""' s owner of the property, or my employees with
ADDRESS a, I GA i27.1 j/
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section - CITY
iZ TLL.N ,
7044,Business and Professions Code).
r
1 v V
OWNER
I,as owner of the property,am exclusively contracting L
with licensed contractors to construct the project(Sec- MAIL
tion 7044,Business and Professions Code). ADDRESS O(
11({
CONSTRUCTION LENDING AGENCY CITY TFI. O (, -LLherebyaffirmthatthereisaconstructionlendingagencyfor
the performance of the work for which this permit is issued CONTRACTORSec.3097,Civ.C.).
I
ADDRESS
Loader's Name H lv Ll C/
Lender's Address
CITY TEL.NO
I certify that I have read this application and slate that the
STATE LIC.
LICFNBf NO. CLASS
a ove inform tion is correct.I agree t comply with all County
r nances a d to I re 104ing o bur ding construction,
an ereby a h n e e sentativ f is County to e ter
o h a o -m a o ropertyf ri p'chon purpo es.r
V
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote
1
c p O mom 7o''a„-c
roo3 f"
5
W O 1,p 6 O Wr n'C Q• p m N , p-
U
p- .
G N 3 b r a 4 ,'
ter
CIL
c f 3° oNoo yN '
TROoIOD
O rtn
i o m
O O n G ._- ep C N
p O F a•O O -' ^
t fS
p - •