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HomeMy WebLinkAbout1477A ' WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERIVIIT I here6y affirm thof 1 hove a certificate of consent to self I i�sore,or o ce�fif��ote of wo�kers Compensation Insurance, ��364C HEATING - VENTILATING - AIR CONDITIONING '� or a certified copy thereof(Sec.3800,La6.C.� , /.'/'(,J���� '�y� �J CE�818(REV.10/81) + P�oIIcyWJ'�Company���F'1117��1.• , Certified copy is he�eby fumished. COUNTY OF LO$ANGELES BUILDING AND SAFETY � �'"Certified copy is filed with fhe county building inspec- FOR APPLICANT TO FILL IN BUIL�MG �, 'Gr� �u��` � �/� f tion deQartmenL �� � , (PRINT OR TYPE ONLY) ADDRG55 � /t.. 9 Date ��APPIicaN LOCALITV �-J— _ �rI � C ' � � NO. TYPE OF APPLIANCE OR EqUIPMEN� FEE / 'L 1 � CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � COMPENSATION INSURANCE CRO55 ST. � (This sedion need not be compleled if The work involved by ABSORPTION UNI7,BTU oniui[�Nu r.e�cEs'sm ov the permit is for one hundred dollars(5100)or less.) � I ce�ti4y fhqt i ihe performonce of ihe work for which this AIR HANDLING UNIT,CFM j /'� y����ft� permii is issued,I sholl not employ qny person in pny monner 1�� `1�t so ns to become subject ro the Worker.s'Compensation Lows, b�ILER,BTU .aPaeovn!s onte i�isvecioe•s siuNnruK� � Date Applicanf J COMPRESSOR,6TU —I � � Uv V - ROUGH d( y� � '[ICE TO APPLICANT: If, after making this Certificate of VEMILATION SYSTEM F�NA� �Z� �� g� �/ j�ption, you shou�d become subject �o the Workers' �ompensation provlslons oi t - -r - -,ycu—.:;t?o;!.". „��,Rr����"C'���� VALIDATI�N � ith comply with such provisions or�ihis permii�shall be �--"�"� deemed revoked. FURNACE: FAU V.FT LICENSED CONTRACTORS DECIARATION � FLOOR &iU � ^ I hereby af4irm ihal I am licensed under provisions of Chapfer 9 HEATER: SUSPEN�FD UNIT_ (commencing with Section 7000)af Division 3 of the Business - WA�� � and Professions Code,and my license is in full force and effect. � j G � �/-7(� Z �--�1 .�/�f �- t� � i License Number��_a_�__Lic.Closs�� , � -1 ✓L� � � i p.7, (q � ( Controcror pote .._ . o i ❑I I am exempi under Sec." � a n W s�r � Picn check fee " � � iB.&P.C.for ihis reason PERMIT ISSUING FEE� ') �(j ' ' "`i�.5 C� `` � Dote: I Signature TOTAL FEE ( �i' ^ � _�I.�(i', � OWNER-6UILDER DECLARATION PLAN CHECK APPLIC.AM Q'y,j (;—�j'7 1 1 hereby pffirm ihqt I am exempi from ihe Contractor's License � � Low for ihe following reason(Sedion 7031.5,Business and NAME � �Professions Code): j� �;, as ovm���F the prope�ty, or my employees with A�ORF55 — wages as their sole compensation,will do the work and ihe structure Is not iNended or offered for sale(Section CITV 7EL NO, 3 7044,Business and Professions Code). /' /�s d ❑ OWNER �/Gr��I.�,QL.. I,qs owner of fhe property,am exdusively controcting MAIL � wiih Ilcensed coniro<to�s�o construtt ihe project�Sec- qDDRE55��� i �. . tion 7044,Business and Professions Code). � CONSTRUCTION LENDING AGENCY CITY ���.- �� 1EI NO.�./�J I hereby affirm tha�there is a construction lending agency far , the performonce of�he work for which ihis permit is iss�ed CONiRaC70R C'�G' t'�G. �% � (Sec.3097,Civ.C J. f ADDRE55 ,l Lender's Name E'� �� - arv it�.No. '�.� S'�G� Lender's Address � STATE LIC. / ^� !� I certify ihat I hove read this application and state�hat the LICENSE NO. �t�r ClrtSS `�/'�—L,CJ . �bove informatian Is mrred.I agree to comply with ali Couniy . ordinances�nd State laws relating to 6uilding consiruction, and hereby authorizc representatives of this Counry to entcr - 'upon the arove-menG�one.d property for�pgctio�rposes. 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