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. SEE REVERSE FOR EXPLANATORY LANGUAGE
� _�Ty� ; /I L�r
E sh
5�g�o�ure of Hpplicant or Ageni Date
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