HomeMy WebLinkAbout1272A • WORKERS'COMPENSATIONDECLARATION AppLICATION FOR PERMIT �
I he�eby af(km iha�I have a ceriificote of consent to seli
ins�re,or a certificate oi Workeri Compensalion Insuron[e, �bA364C HEATING - VENTILATING - AIR CONDITIONING
� or o cerlified copy thereof(Sec.3800, 6.C.) . �_Bie(aEv.lo/el)
p�olity . ` I om��yi �[� �
Cer�ified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
Certified copy�s filed with the county building inspec• FOR APPLICANT TO FILL IN BUIIDING
�ian deparfinent. ADDRESS O � /t����
r f I� � i� //� (PRINT OR TVPE ONLV)
Date Applicant 6LX�� T7
LOCAUTY 7 �� ��
NO. NPE OF APPLIANCE OR EOUIPM,EN7 FEE � �/
CERTIFI�OMPENSATION�INSURANCEORKERS' Ce05555T. /jjj ��kn(r�U�2[G�
(Thfs sxtion n�ad noi ba complaf�d if tha wo�k Invalved by ABSORaiiON UNIT,BTU �ISiRIC�NO. PROCESSEO BY `
th�parmif is fvr ono hundrod dollars(f100)or letf.) . � y�'
I cerlify that in the per(ormante of Ihe work for which this AIR HANDIING UNIi,[FM 1`\
permit is issued,I sholl not employ ony person in any monner ' ' `0.\a�1�
so as to become subjeU to�he Workeis'Compensolion Laws. BOIIER,BiU AVPROVALS OATE INSMCTOR'S SIGNAiURE
Dole opplicont COMPRESSOR,BTU D� �(' � ROUGH I a�f �' �,��
NOTICE TO APPLiCANT: If, atler making this Certifimte of vENTItATION SVSTEM F�NA� Z-Z�Y"� C9-'—�
Ezempfion, yau should become subjecl �o the Workers'
Compensation provisions of the Lobor Code,you must forfh• EVAPORATIVE COOLER VALIDATION
with tomply wilh such provisions or Ihis permil shall be
deemed revoked. FURNACE: FAU AYJZY
� LICENSE�CONTRACTORS DECLARATION F�OOR a7U � . -
I hereby a(firm ihat 1 am licensed under provistons of Chopter 9 SUSPENDED UNiT_
HEATER: wA��
�(commencing wiih Section 7000)of Division 3 oi ihe Business }
and Professions Code,and my I�cense is in foll force and effett. � v 19 Z a
License Number��/ 3 Lic.Class� � , O
�� ,�/��7 p.,
CoNractor f `v Da�e ��w^ �=� 2 7 L-�1 O
❑ I am exempt ondei Set. $�• • • . .� W
Pian check fee a
B.BP.C.for this reason pFRMIT ISSUING FEE S O � � • •U`�,7{ Z
Dofe:
Signature TOTAL FEE • • •�l�,`.%5�,
OWNER-BUILDER DECLARATION MAN CHECK APPLICANT G C�.J� —CZ,d
I hereby offirm that I am eaempt from the Caniradar's License ,
I Law for�he foliowing reason(Section 7031.5, Business ond NAME
Pro/essions Code):
❑ I,as owner o!Ihe property, or my employees wilh /+DDRESS
oges as their sole mmpensation,will do the work and CITV TFL.NO.
� �he struc�ure is not intended ar ofFered for saie(Sec�ion
7044,Business ond Crofessions Code).
OWNER
❑ I,as owner of Ihe property,am o.clusively tonlracting
wilh licensed conlrat�ors io cons�ruct ihe projeU(Sec- ADDRE55 /- �
� tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CRY � TEL O. � �Q
I hereby afiirm Ihal�here is a construction lending agency for ,
the performonce of Ihe work for which ihis permit is issued-- -- CONTRACTOR
�Sec.3097,Civ.C.�. � _ �
ApDRESS �G � � ' . �
Lender's Nama
CITY /]�'1�L TEL NO. JL .� . - . -
Lender i Address ` � '
I tertiF that I hove reod this a Iicaiion and sto�e ihat ihe SiaiE �iC.
y PP UCENSE NO. C1A55 C' -
above information is correcl.I ogree to comply with all County
ordinances and Slale lows relating ta building consh�ction,
and hereby authorize representatives of this Caun�y to enter �
upon the o ove;en�ioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signo��ont or A� '��re . . .
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