HomeMy WebLinkAbout8644AWORKERS'COMPENSATION DECLARATION
APPLICATION FOR PERMITIherebyaffirmthatthavecertificateofconsenttoself
orsare,
or a certifate ofcertifiedcopythereof
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Sec.3800,
LCompensation
n
Insurance,
76A3e4C HEATING - VENTILATING - AIR CONDITIONING
CE-818(REV.10/81)
Policy No ! I Companylirn
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- I„ 1 JFORAPPLICANTTOFILLINBUILDING
l 1' VUl 1 _tion department. ADDRESS
II //fc.,, PRINT OR TYPE ONLY)
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Dote Applicant l L4 ,
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11111 - tV +
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALITY L
j CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. l7'
This section need not be completed If the work Involved by
ABSORPTION UNIT,BTU DISTRICT N0 PRO1E55E1 By
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this
AIR HANDLING UNIT,CFM t n
permit is issued,I shall not employ any person in any manner
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so as to became subject to the Workers'Compensation Laws. BOILER,BTU APPROyAIS DATE INSPECTOR'S SIGNATURE
COMPRESSOR,BTU - W'
q(O ROUGH
gypp' Applicant
A CE TO APPLICANT: If, after making this Certificate of VENTBATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU C gQV,fTa;_ /jT jl
I LICENSED CONTRACTORS DECLARATION FLOOR BTU 7S.11Y_Cl LlJ 11C
I hereby affirm theft am licensed under provisions of Chapter 9 SUSPENDED--UNIT—
commencing
USPENDED _UNIT_(
commencing with Section 7000)of Division 3 of the Business
HEATER: WALL
1 and Professions Code,and my license ism full force and effect. 7 nlJ`tk_& O
License Number_: Lic.Class
tL
Contractor Date w
I am exempt under Sec.
Plcn check fee 0.
B.&P.C.for this reason U3
I PERMIT ISSUING FEE$ /JDate:
il{
TOTAL FEE ;, 4Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 8 b U' n
W for the following reason(Section 7031.5, Business and (NAME
a. Ifessions Code): a °f
J 1, us o r
ADDRESS
caner of the property, o my employees with v 5,r J
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TF1_NO.
o + rj_r,.G 55
7044,Business and Professions Code).
OWNER
ti J1,as owner of the property,am exclusively contracting O _2 6—8 7
with licensed contractors to construct the project(Sec- MAIL C"' (D a.,(1,It a
iii tion 7044,Business and Professions Code). ADDRESS (`1 S• CA
CONSTRUCTION LENDING AGENCY CITY. TEL.NO.
I hereby affirm that there is a construction lending agency for
the perforrna nce of the work for which this permit is issued CONTRA
Sec.3097,Civ.C.).
1 '
Y,` (- ^V•
ADDRESS 11 n` Gn Ytn ru a ,Lender's Name lSl t YJ ICU -
TCITYE( TEL.NO',f 1.f(6lCS(K)Lender's Address 11 v 1U-1`./
STATE LIC. n.I certify that I have read this application and state that the LICENSE NO. 4k4j CIA S$
above information is correct.I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
up thabove-mentioned property for ins coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Apph-1 or Agent Dote
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