HomeMy WebLinkAbout1281A (6) . 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 , �
� � ' /
Z • .
-`�o .
�
�
� �• '
N , .
Z ,
O . .
N �
� �
. �
, � �
�
b
' ��
N
�
. . �
r� . N
1 .
+ � .
� W
H(l�C .O �^ y �'
. N �p O l0 • C � f:
� �� O � 3 7 �D ' N O ff
�� a� = � po '^ � � � ��` O
' _. � '� o ^ o o N T n� � Q�-� a o 0 0 !L .
, . � O �X b n �O �'�C C 7�n O V` p,,,O b.7 C> >� A' M Z
. � � O � � ^ O a. D' O n `� 'n tl-c �v o�n C1'6 .�, 'C p� �s1
� �^ o ,�� � s � ��'c.� s�. c' o �`or. � � o� �«�D�3 0 � 70 .
6i O p^a G'- o`ofl cc•� o � �� Q3c N� � oK,onn.��..� �� ^o N�� C _
• O O � � , 3 0 -' N'��'� ° n._ o �o � H � ? .. ,�v n o Q o 7 G ^ o C r
�v � �N So � _ v � Non � . xs'N. �� o ro � „ °3 �
' ' �L f� � x O n C1 3 �r fJ j O ^ h N Q 6.�, � O tT�
a � ^ o r.N n o .fl � � o °is o`" � � � 3.N o .�v c.o Q f,x 7�'�
.. 3 �-� � ° � m � o =Ofl-a.� � � n' �' � "� �-' } �.^ ��-5r, �
. � o v r �v Q N� � � `g o°-a o °"a`'' o a� 'x' o sc.° o ,a°`� � n
n-o, � � v 3 .3 � ° � � r
, ' N a n o o � � � o m �c o e o 0 0 0 ,°9-�,v T�� 3,° � � o -�- 'D
� t� � ^ �, ' °'3ei T� � � �v � 9 3 �� 3° ' ° � ^-.� 3 �
� ° � �� v o ::c n "' ° n m .o o � q
, O n � � �'�O ^O-"��� C C � •7 �O O ^�• O 3•.C.f Gn^CJ -, v''30� i/�S �
f_e,v� N v �-o s N £ � -.o ,�y �o c p � m �+ Z
� � ?"' � �� ° ° �c,v � ° ° � a A v,°•3 N 3 ° �, n �' c o v
'o ° '� �i ° t c t'-o o �n � a � 3 «� o 0 3
--o a � a �-oono f !=. �, _.^.� � 7 � 03 ' �,'-� r,Q
_ °-o o? � a ° p� 34'O �n� � y' °a��N n'"—a t� w=
� f n'' c� ° � ° ° �'o a o cno �`n o N o ': o
. . � p � �' n� Q ta� �� Q_'^ ^ b C Q n �O � ..O � T T u� u.
. �^ f� .-� N �7�G '^ Oy.'O p '7�' Q.p .� � q-' Q 0 . _/�
� o o n s � a o Qo N � � a �v j N a �'
. . , . � �vn" `° T? � `� � ° � n, n- '
'yr O O'O -G p 1'J � ^� f'
_ Q �� � O n d 7 O � ��
� a m Q�n? p-co '` J_,-,�
O �K n �
' '/
_'�
' _-' ��