HomeMy WebLinkAbout1648A (9) t �
WORKERS"COMPENSATION DECLARATION qpp��CATION FOR PERMIT
I hereby affirm that I have a certifimte of consem to self .
i�s�re,or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec 3800,Lab.C.) 76A364� ,
CE-SIB(REV.10/81)
Policy Na Company
� Ce4.�ified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAPETY
� Certified mpy is filed with the munty building inspeo FOR APPLICANT TO FILL IN BUiLDING p/— �
� tion depaltmenf. ADDRE55 �JW i
(PRINT OR TYPE ONLYJ
y Date ApplicaN LOCALITY� ��
NO TYPE OF APPLIANCE OR EQUtPMEM FEE b��
! CERTIFICATE OF EXEMPTION FROM WORKERS' - Nenkesi ,(
COMPENSATION INSURANCE CRO55 SL ��C'.�AS \
� (This aeefion need not be eompleted if the work involved hy ABsoePiioN uNiT,BTU oisTaia No. veoressFo nv �
the permit ia 1or one hundred dollaro(5100)or loss.) qIR HANDLING UNIT,CFM
� I certify that in the performonce of ihe work for which fhis �a �'� �
8 permit is issued,I shall nm employ any person in any manner gOi�ER,BTU '�.� U'�
so as to 6erome subjeci to ihe Wojr�kers'Compensation L(1W5. APPRWAlS unre iNsrF roe�s s Nnivae
Date �� �Applicant WYV��WI,VV�� COMPRESSOR,8iU ROUGH y'���..� {������ � �
NOTICE TO APPLICANT: If, after making Ihis Certificate of VENTILATION SYSTEM FINAL �("y „�-�
Exemption, you should become subject to ihe Workers' - ,
Compensation provisions of the Labor Code,yov must forlh- EVAPORATNE COOLER VALIDATION
with comply"with such provisions or ihis permit shall be . ,/
deemedrevoked. FURNACE� FAU_GRAVITY
LICENSED CONTRACTORS DECIARATION F�aoR Biu
' I hereby affirm fhat I pm licensed under provisions af Chapter 9 HEATER: SUSPEN�ED UNIT—
q �(commenting with Soction 7000)of�ivision 3 of the Business � WALL
� and Profassions Code,and my license is in full force and eRecL �
�
License Numher Lic.C�ass ' �
°'I648A �
Confracfor Date j��, a n a o£j �
❑ I qm exempt onder Sec � : o x - �
Plan check fee G%G �
� B.BP.C.for this reason .._, y
PERMIT ISSUING FEE$ L O y� �'._`;;�-��, �
a Date: � ��� �
� TOTAL FEE 0 �d p'?,1 :S I
� Signoture �v�
'�� OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I herehy affirm iha�I am exempf from ihe Contractor's License � �
� Law for the following reason(Section 7031.5,Business and �NAME �u ���' ��
Professions Code): j
�, I, as ownar of Ihe property, or my employees wiih A��RFSS �� � � P ��
� wayes us iiie�r sole cor���;e��su'ion,':.'ill dc'he v✓or��and ^
ihe structure is nof intended or offered for snle(SeUion QTY �. TEL NO. "�u_ ^ L
7044,Business and Professions Code). OWNER �p t
❑ I,as owner of fhc property,am exdusively wnirac�ing � �
with licensed coNracfors to tonstruct ihe projed(Sec- qDDRESS � �
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ai i" .. -�ie�.NO. �(�._� '`�'
I hereby affirm thnt there is a construdian lending ayenty for � ,� , ,
the performance of the wark for which fhis permit is issued CONTRACTOR
(Sec.3097,Civ.C.).
� nnoRess
Lender's Name
I . � CITY iEL.NO.
Lender's Address
STATE ��C.
I I certify that I hove read this applimtion and state that the LIC[NSE NO. CLASS
nbove informotion Is mrrect.I agree to comply with oll County
ordinances and State laws relnting fo building consiruction,
and hereby authoriie representotives of fhis County fo enter
u on the above-mentioned prope�iy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�.�� Cta�` - _�
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