HomeMy WebLinkAbout1273A (6) WORKERS'COMPENSATIONDECIARATION qpp(,�CATION FOR PERMIT � - �
I hereby affirm that 1 hove a certifito�e oi tonsem�o seli
insure,or a certi{��ote of Workers'Compensation i�s��o��a, HEATING - VENTILATING - AIR CONDITIONING
�or a tertified topy Ihereof(Sec.3800 ab.C.�� 76A364C
/-' CE-B16(REV.10181)
��YO��G 27 ompon, �
CerrHied copy is hereby furn�shed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Qp�`yy�—Certified copy is f�led wiih the county b�ilding Inspec- FOR APPLICANT TO FILL IN BUiIDiNG s�
!— �ion dep�arlment. (PRINT OR TYPE ONIY) ADDRE55 a �� s(,� /�l f/[t/' •
Dote � • Applicanf LOC/+LiTv�
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �
COMPENSATION INSURANCE CRO55 ST. /'— rrl/T (�
(TI+I���c11on n�ad na}ba complsfad iF tho work Involvad 6y ABSORPTION UNIT,BTU Di51RiCi NO. VROCESSE�9Y
}hs parmiM i�(or ona h�ndrad dollarf(SI00)or lasf.) -^,,
I te���iy ihol in 1he performance of ihe work for which fhis AIR HANDIING UNIT,CFM ` O �``Q 1 O� �P
permil is issued,1 sholl not employ any person in ony manner
so os to become subject fo ihe Workers'Compensation Laws. BOiIER,BTU nrvaavnis DATE INSFECTOR'S SIGNAiURE
Da�e Appliconl COMPRESSOR,BTU � /V � ROUGH j�fF ��n... v
NOTICE TO APPIICANT: If, afler moking Ihis Cerli{imte of VENTILATIONSYSTEM FINAL �j2��}✓ �
Exemption, you shoold become sobjeU to the Workeri
Compensotion provisions of Ihe Labor Code,you must forth- EvneORnTivE GOOtER VALIDATION
wi�h comply with such provisions or this permit sholl 6e
deemed revoked. FURNACE: FAU_G I /�
IICENSED CONTRACTORS DECIARATION FIOOR BTU
I hereby aHirm rhot I om licensed under provisions o1 Chapter 9 HEATER: SuSPENDED UNIT_
�(commenting with Sedion 7000J of Division 3 of ihe Business WA«
and Professions Code,and my license is in fuli force and e((ect. / �'7� a
I / r�+_7� ( `
License Number "� � lia Class y `^-' ► �� 2�,J r� V
r �� '� a
Commcfor � Dofe I ~ � � � � �
❑ I arn e:empt under$ec. � • �.�>J�C Jr w
Plan theck fee °�
8.8P.C.for this reason � • e e 5 J 7 J�; Z
PERMIT ISSUING FEE S
�are: 0$3 1 —f3 8
I
Signature TOTAL FEE 3
� OWNER�BUIIDER DECLARATION PLAN CNECK APPIICANT
�� I hereby affirm thot 1 om esempl(rom Ihe Conhaclor's license ,
law for the following reason(Section 7031.5, Business ond NAME
Profe:sions Code):
❑ I, as owner of ihe property, or my empioyees with
AD�RESS
ages as their sole compenzation,will do Ihe work ond CiTY 7E1.NO.
the strocWre is not intended or offered for sale(Section
7044,Bu5ine55 and Prolession5 Code). OWNER
❑ I,os owner of the praperfy,am exdusively ConfraC�ing MAtI � G�`
with licensed mMmUors�o construct the p�ojed(Sec- ADDrrESS �r / �
tian 7044,Business and Proiessions Code).
GONSTRUCTION LENDING AGENCY CITY t �Q TE.NO. S'�i/�Q/
I hereby affirm that there is a constroc�ion lending ogency ior ,
the performance of�he work for whfch this permii is issued CONTeaCTOR
(Sec.3097,Civ.C.). - � ,
ADDRE55 � r� �� �
Lender's Nome
CITY � TEL.N0. � (� .
lender's Address
STATE �f UC. �� •
I certify that I have read�his applica�ion and sta�e ihat the LiCENSE n10. Y C�ASS - - � . - .
above informa�ion is wrreU.I ogree to comply with aIl Counry
ordinances and Srate laws reloting ro b�ilding canstrucrion, _ _ _. _ . . . .
and hereby au�horiza representatives of this County m enrer
up the ab ve-Aen�ioned proper�y for inspeUion purposes. SEE REVERSE FOR EXPIANATORY LANGVAGE
r
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Slg�o�u�e o App�ico��or Agen� Date
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