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
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