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HomeMy WebLinkAbout1478A � WORKERS'COMPENSATION DECLARATION APPLICATION �FOR PERNIIT + I hereby affirm that I have a certificate oF consent to self � � insure,or a certificate of Workers'Compensaro��Insurance,, �6a36nC HEATING - VENTILATING - AIR CONDITIONING or a certified copy ihereof(Sec.380D,Lab.C.) ��� � �> �j J� � (f� CE-818(REV.10/81) j P❑ollc�k�.�Company Z�� � Certified mpy is hereby fumished. COUNTY OF LOS ANGELES BUIIDING AND SAFETY � Ce�tified copy is filed with the county b�ilding inspec- FOR APPLICANT TO FILL IN guno�N�/�//I �j,t�y��f-- �✓/A � � ti�depattr��fineM. �� (PRINT OR NPE ONLYJ .4DDRE55 f�y� �L 's Date_f_�-�Applimnt �/ LOCALITY _ l7-�-1- L��� NO, TYPE OF APPLIANCE OR EQUIPMENT FEE �-� � � CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE ce055 si. d (This secfion need nof be complefed if the work involved 6y ABSORPTION UNIT,BTU oisruict No vaocessco av � Ihe permit is for one hundred dollars(5100)or leas.) � AIR HANDLING UNIT,CFM p�� \Jh�+ � I certify ihat in the performonce of the work tor which ihis a � ��( � � permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER,Biu naNeovnis onrF iNsvecrok's sieNaTuaF Date Applicani , COMPRESSOR,BTU -r u ���+ � ' ROUGH ��f ,� � [t: P' CE TO APP�ICANT: If, after making ihis Certificote of VF.NTILATION SVSTEM RNAL L'�,s�� �ption, you should become subjed to ihe Workers' � Compensafion provisions of fhe Lobor Code,you must forth- EVA.PORqTIVE COOIF.R VALIDATION with comply wifh such provisions or ihis permit sholl be �- � deemed revoked. FURNACE�. FAU G TY �� LICENSED CONTRACTORS DECLARAiION F�ooe Aiu � I hereby affirm Ihat I am licensed under provisions of Chapter 9 SUSPFNDeO UNIT- HFATER: WA�� � �(rommencing with Section 7000)of Division 3 of the 8usiness and Professions Code,and my license is in full force and effecf. ,,i� '�' '{ 7 / � f-� �� .f� � License Number 7� � Lic.Class � `-���'� ► 6J � Coniracror� Y� � � Date i t�� �'I ��(,�/` � � ❑ 1 am exempt under Se. o�% Plan check fee ` � � o a g e� � i e.&v.C.for this reason PERMIT ISSUING FEE S � � --. Date: v � J ..� .;/�Q 7.ri, � TOTAL FEE Signoture `7 a '�'=:�!.'f: i�.x'a OWNER-BUILDER DECLARATION ' PLhN CHFIX l�PPIICANi g I hereby affirm ihot I am exempt from Ihe Conhoctor's License ' {��}�' �=���� � Law for the fol�owing reason(Section 7031.5, Business and NAME � Professions Code): . � �� � ADDRE55 g I, as owner of ihe property, or my �mployees wifh � � wages as 7heir sole compenspfion,will do the worK and � the structure is not intended or offered for sale�Sec�ion C�iv ieL.NO. � 7044,Business and Professions Code). 7� ❑ OWNER ? C���,_ p I,as owne�of�he property,qm exclusively confrading { with licensed mMratlors to mnsiruct ihe project(Ser MAIL - ` � �ion 7044,Business and Professions Code). ADDRESS �/�µ CONSTRUCTION LEN�ING AGENCY � a7V �S�-/ ���,�,_ 7EL.NO. '���i I hereby affirm thai there is a construction lending ogency for `� ► the performance of the work for which this permit is issued � CONTNACTOR �_�� �� � (Sec.3097,Civ.C.). � /�J�l��e Gf � - ADORE55 '� y� � ,J�t lender's Name / 7 Lcnder's Address t CITY �� TEL NO.'��j���G�/� �� STATE �j`f� LIC. 7 i certify thal I hove rend this application qnd state that ihe ... LICF.NSE NO. 7 7 CLASS •�"L-�.. . , above informofion is mrrect.I agree to comply with all County ordinances and State laws relating�o building consirudion, and hereby authorize representatives of this County to enter upon ihe ab ve-mention�propeny for ins ection purposes. $EE REVERSE FOR EXPLANATORY LANGUAGE I � � .�-� � 3 r 1 i�nai�re af Appli<ant or Agor i Dato � 1 ; � . \ i 1 1 ,` � �` \ \ � ��, � ��� . � � � n , � , , � � ; � ,\ ; �, �� � � ��, �� � � � � � , .� , �,, '� � ', � \ �\ � � � , �, � � , , � � � ��� ; ` � ` � , ; � �i \� � , � \ , r �. ,! �1 � � `��\ ` � �\ ' � i '� ` � 1 ��, ,, \ ;� � , � , ;�,. \ 4,�,,, 1 \ � 1 � 1 i� �, '�� �'' � ,�\ ,\ i � \ ` ` `� ; \ ' i o��\ ` \ ` ` ,� ` '' , 1 � �r� `� , i , � � ':� , � , '�` �. 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