HomeMy WebLinkAbout1281A . WORKERS'COMPENSATIONDECLARATION AppLICATION FOR PERMIT �
I hereby offmm tF�ot I have a ceriifica�e of consent�o self
insure,or a cerrifica�e oi Workers'Compensaron Insuronce, �6A36eC HEATING - VENTILATING - AIR CONDITIONING
'or o cer�iited copy rhe�rjeof(Sec.3800 ab.C.J � CE-B16�REV.10/81)
��y N C �/Z/� ompany �• . . .
CerriFied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Y,Yy�1F- Certified topy is filed with the county building inipeo FOR APPLICANT TO FILL IN BUIIDING �t'
/— tion deparfinenl, �� ((J �PRiNT OR TYPE ONLY� /+DDRESS Q LJ�J�/rZ/— �
Do�e � � � AppliConf �"� � NO. TYPE OF AFPLIANCE OR EQUIPMEM FEE ���ITM " '`�"" , '�� • �
CERTIFICATE OF EXEMPT�ON FROM WORKE ' NEARESi /J
� COMPENSATION INSURANCE CROSS ST. � J(/!%�t�� /L(f
(Thl�secllon naed not be complat�d if 1hs work Involved 6y aB50RPTION UNIT,BTU DiS�RiCi Np. GROCESSED BY
the parml}Is For one hundrod dollors(5100�or less.� c
I certify Ihat in Ihe performanta of ihe work for which Ihis A�R HANDLING UNIT,CFM � � t/� Q\ O��
� �\ \
permit is issved,I shall not emplay any person in ony manner
so as to become subjed to the Workeri Compensafion Laws. BOILER,BTU povaOvntS oar[ MSMCiDR'S SIGNATURE
Da�e APPlicant COMPRESSOR,BTU v �/�v Q � ROUGH �f�� �����,
NOTICE TO APPLICANT: IF, aFler moking this Certi(itale of VENTILATIONSYSTEM FiNnL 22p
Exemption, you should become subjett to the Workers'
Compen5alion provisions o1 fhe Labor Code,you mu51 Forlh- EVAF'ORATIVE COOLER VALIDATION
with comply with s�ch provisions or this permit sholl 6e
decmed revoked. FURNACE: FAU G�qy IiY /
LICENSED CONTRACTORS DECLARATION FIOOR BTU lvvi��� !O �
I hereby aifirm�hot I am licensed under provisions oF Chap�er 9 HEATER: SUSPENDED UNIT_
�(commencing with Section 7000)of Division 3 of 1he Business � WA«
and Professions Code,ond my license is in full force and eifecL � }
a.
License Num6er �� Lic Class �^�� n.� 2�.� � V ,
(�/f ' �
Conlra[tor Y Date� �i•�� • e s Qi v
� ❑ I om e.empi�nder Sec. plan check fee � � 9�a 2 5 a
8.8P.C.for this reoson �n
PERMIT ISSUING FEE S Q ,5� � � _`���' Z
Dare: . .._ "
Signature TOTAL FEE ,�j 'y 0�.3 1 —3 8
OWNER�BUILDER DECLARATION PLAN CHECK APPUCANT
1 hereby a((irm�hat I am e�empl from�he Controdor's ticense �
Low for ihe following reason�Secrion 7031.5,Bvsiness and NAME
Professions Code):
❑ I, as owner oi ihe properry, oi my employees with ADORESS �
waqes as theh sole tompenso�ton,will do ihe work and CiTv TEL NO.
�he shuciure is not intended or offered for sale(Section
704E,Business and Pro(essians Code).
❑ OWNER �
I.as owner af the properfy,om ezclusively tonfrocling
wilh licensed contractors ta cons�rutl�he projed(Set- ��� �
tion 7044,Business and Professions Code).
ADDRESS /lu/ �
CONSTRUCTION LENDING AGENCY arv � � TEL.NO. S�J�Vd
I hereby affirm�hai there is a construction lending agenty ior , -
the perFormance af Ihe work for which this permit is issued COMRACTOR
(Sec.30ff7,Civ.C.). /� � . _
ADDRE55 -�// /am�,C2! CJ--- � -
Lender's Name ��� `�v U�
CITY TEI.NO. �—(,
Lender's Address /�C� /�/)� �
I teriiiy Ihat I hvve read ihis opplitalion and s1a1e Ihol Ihe ��ENSE NO. �d� � CLA55 �/rC�O . '
obove iniormalion is torred.I agree�o comply with oll County • �
ordinances and S�o�e lows rela�ing�o building construciion,. �
and hereby oothorize representotives of this County�o en�er � � � �
upo ihe above-menrioned p�operty for inspecrion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� � -Zr-�
5�9�oNre o ppliconl o�A9ent Do�e , �
t
� : ...
m •
a . . , •
O '
� .
N '
z ' � '
o ,
�
� ' � '-
1 � � N
' !
m
n
�
. _ , o
, , N
4
� Q
�
i . m
. N
� �rt3� ° � � � � .
• � .o
. o � f £ o � o °� u'� N o� a Nv N N� cr
� 3 � su:^ � ° 'v+�'n� o a
� ' V+� O �f-p �'7 �� �' . �. D '� � Q � O
. � � T n Q N'� O. .Q'� O a.�-O'n p±-�n � < 0 Q'4 O� S O p'O Q i �.' �z '
Q n ? j C Q .�. C 'F fn O v O v� �`p 7 1'J
� O o Q° � ov c'` o� ❑ cc 3a� „ti' � n ° o`-' � c n �� ��Y_'—. M3.o � 3 m
`L 'b � � -'� .n f � . w o c � °i �-�."� .,, o, � ... � T '� .
^ � (1 � n%� u�'. �p 7� a �� °,"° c '" � � a v 4 o d' e"o ?n o N �� � �
3 ^ N o �N :a 3 N �� f No c, �T�.x =,� o .�. c' o` '" C
' O �p � a n £ '6 `L� u� a ? 6. . o � 1� v'� r�J O O N o C T
� m �o � �-no '^ � a o `D ot.i� � � 3 �
' c ��' 3 n.N �'. ^ < 7 p-�4-p ° ° � <' �-�c �� �E ts c � n°
� 0. � O � � C ¢O. p m F� �, 6'G � ��(] �.O O n � C�N�O� �O� � �
� ^' � ^ �, � n.� 's s�° � o o °'� o a �•3 °o o � o`� � n
-n
' p � �� �o �?c� ?c � � H �'v � � �0 'vD.= �-� = 3 ° � � o r'
m �� � o o � a o.ov � �'� �c �,�� o -. 3 `� -'c �-.° o ' — '` oo" T�
- f �e,v m N b c o 3.o o �. 0 3 � o�,o 'o '" � � 3 70
„ o o .� '^ m -o m< o °�a N c� � n �'�:.� � � " 3K D�
`e 3 � ia _ V`.n ='"v o
=oo ? o'�` 'a. o � ov � � o�= ovpO N3o � ° � ^�' � .
� -�� �o a M� o �, o �-� a'o o �� o a N 3 < �,', c� � Q o Z
. ? � ° �N� ° a� � 4�' .n � K�'�..� �°a � 0 3 ° d y � �
, . � ' �r,� 7� ° � � Q� 3 �o ° �z o � " �.��.°-S M a.°3� o°
. d� �� 'y " G v W T3 C"� Q_ O O �'n �n t] �fL1 p,N p O S�?'O
. � O O D 5�. 7 r�.� N� � j�' a ro n Q O � � � 7,ir,a
3•O fl(� N Cl O C1 D � > Qro N � �. D� . S
�" 0 D'D -e �'� � � o � j O =j n � S r.l�
o w-°u 3 0.o o-?a o ^ ,K� o. a ' �'_
' � � o i� � 4 m � Y'�
�
0 0-� _.�
, _,�....r
�._��-
�-,�—"`