HomeMy WebLinkAbout1287A WORKERS'COMPENSATION DECLARATION �
I hereby of(Km thol I have a cerlificote of consent io self APPLICATION FOR PERMIT
. insure,or a certificate of Workeri Compensation Insvrance, 76A36aC HEATING - VENiILATING - AIR CONDITIONING
or a ce�lilied copy thereof(Sec.3800,(ab.C.), CE-e1B(REV.IOie1J
OcY / � ompany � �
Certified copy is hereby furnis ed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy is filed with rhe caunry building inspeo FOR APPLICAN7 TO FIIL IN ADDRESS � r
rion eparrmenr. �, �pR�NT OR TVPE ON�V) � � �� ('�� �!
Da�e l l' '������ � NO. TYPE OF APPUANCE OR E�UIPMENT FEE `�L'Ty � �L✓ '
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST • ' ./
COMPENSATION INSURANCE Ca055 ST. iC(� r�u i7Jrlt�T— /G�-
(This s�cfion naad nal be compbfed if fho work Involved by ABSORP1i0N UNIi,BTU D151Ri�7 NO. VROCESSED BY
the parmH is for one hundrod dollors(5100)or le�e.) �Q
I terfify thot in Ihe performonce of the wo�k for which Ihis AIR HANDLING UNIT,CFM
a onE
permit i5 issued,I shall not employ ony person in ony manner gOILFR,BTU
so as to betome subjec��o�he Workeri Compensofion laws. avvaovn�s DAiE INSCECTOR"SSIGNATURE
Dale aPPlican� COMPRESSOR,BTU vUJ �Q �� ROUGH L��'� ,
NOTICE TO APPLICANT: If, ofter moking this Cerli(ico�e of VENTILATION SYSTEM FINAL '� �j�__.
E.emp�ion, you should become subjeU �o ihe Workers'
Compensafion provi5ions of ihe Lobor Code,you must forth- EVnPOrtn7�vE COOIFR VALIDATION
wilh comply wilh such provisions or this permit sholl be
deemed revoked. iURNACE: FAU_Gq[sV Y � �
LICENSED CONTRACTORS DECLARATION� FLOOR aiU -/ �— �O
I he�eby affirm Ihof I am licensed under provisions of Chopter 9 SU57eNOED UNIT_
�(commencing wiih Section 7000)o(Divrsion 3 oi the Business HEATER: WA��
and Professions Code,ond my license is in(ull force and effecl. s� Y
' �(� /'�'7� / �L
License Nombr.r �/"�� Lia Closs�(� , V
�� L�?7{�1 �=
ContraUor � Dafe�J� �
jteo • o sF �"
❑ V .
I am exempt under Sec. W
Plan check fee
6.8P.C.for ihis reasan� ( e e F�,�O N
Daie: PERMIT ISSUING FEE S � � a � _ ?
Siqnalure
TOTAL FEE ,� ��i,:�^�
OWNER-BUILDER DEC�ARATION PLAN CHECK AFPlIC4.NT ���� —&b
I hereby of(irm ihat I am ezempt from the Contractor's License ,
Law for�he followfng reason(Sed�on 7031.5,Business and NtUnE �
Prciessior,s Ccde�:
❑ I, as owner of the property, or my emp�oyees wifh /+DDRE55
wages os iheir sole compensation,will do Ihe work ond
rhe struciure is not inrended or oifered for sale(Secrion ��iV TE�.NO.
7044,8usiness and Professions CodeJ.
OWNFR l �_
❑ I,as owner o(ihe property,am exdusively toniracting
wiih I�censed contractors ro cons�ruct rhe project(Sec- MA�� ✓ �y�
tion 7044,Business ond Professions Code). /+DDRESS �j r� / =tr � .
CONSTRUCTION LENDING AGENCY CITY �f� TEL NO. S�i�
I hereby affirm thot there is a constr�ction lending agency for
the performonce of Ihe work for which Ihis permil is issued CONTRaCTOR � ��j/ ,
(Sec.3097,Civ.C.). .
A�DRE55 �P � '
Lender's Name
CITY . TEt.NO.
lender's Address ( ( (/'�/, �7� �
I certify�hal I hove reod�his appiimtion and s�afe�hat Ihe ICENSE NO. �'1�4 iJ`T CWSS �(r-PJ .
above information is conect.I agree to comply with oll County
ordinontes ond Sto1e lows reloling to building construtlion,
and hereby authorize representatives of Ihis County to enter - � ' -
�pon the obov -me�tioned p�operiy fo�i��tio?�u� SEE REVERSE FOR EXPLANATORY LANGUAGE , �
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Si nolme af Appltcanr or Agenr Da+e , - -
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