HomeMy WebLinkAbout1288A • WORKER$'COMPENSATION DECLARAT�ON �
I hereby offhm that I have a certificate of tonsen�io self APPLICATION FOR PERMIT
.insore,or a certHimre oi Workers'Compensaiion Insurance, 76A36aC NEATING - VENTILATING - AIR CONDITIONING
or o cerJtif'ed copy thereo(($ec.3800,La6.C.� � CE�81B(REV.10/81J
O�YhV��mpan /t
Cenified copy is here6y furnishe . COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy 7s fled with the coun�y building tnsPeo FOR APPLICANT TO FILL IN eunoiNc � n %��r n�.,�
Da�e��ian depOrfm n1. (FRINT OR TYPE ONLV) P.DDRE55 »
Applicant �'+"� IOCA�ITY .{� ('�
NO. TVPE OF APPLIANCE OR EQUIPMENT FEE P�
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAaEST + . �
COMPENSATIONINSURANCE CROSSST. �ryJ� �yjM�
(Th�f fatl�on nood no}bo complefed if}ho work involved by ABSORPTION UNiT,BTU pl$1GIC1 NO. GROCFSSED BY
}he parmit If(or one hundrad dallo�s(5100)or Iess.� qIR HANDLING UNIT,CFM �O ,(�,� �\O�
I certify Ihal in the performonte of the work for which this ` ��
permit is issued,I shall not employ ony person in any manner
so as to become s�bject to the Workers'Compensation lows. BOILER,BTU AVPROVAlS DAiE INSCFCIOR'S SIGNAiURE
�a�e �pplitanf � � fOMPRES50R,BTU � `(„� ROUGH 93p �'� �H,w
NOTICE TO APPtICANT: If, aftcr moking this Certifica�e of y[ryTILATION$VSTEM FINAI 27 G `
Exemption, you should 6ecome subject to the Workers'
Compensotion provisions of Ihe Labor Code,yvu must forih- Eyq�pRATNE COOLFR VALIDATION
with comply with such provisians or Ihis permit shall ba
deemed revoked. FURNnCE: FAU G V Y
LICENSED CONTRACTORS DECLARATION FLOOR siU O
1 here6y affirm Ihot I am licensr.d under provisions of Chopler 9 SUSPEN�ED UNIT_ -
HEATER: WA��
�(commencing wi�h Section 7000)of Division 3 of the Business
and Professions Code,and my license is in(ull force and effec�. � � }
1' 7 v 1./.. � n.
License Nomber `'� J Lic.Class� � , - , O
�/ �� .�� GB.��{ �
CoMrador � Dote Q
•❑ � . c F-
I am exempl under Set. �`� � ��' V
Plan check fee � , �5� ��� "'
8.8P.C.for this reason� �
N
Doie: PERMIT ISSUING FEE S U � �,-. `;.�` Z
Sgnature TOTAL FEE �
- OWNER-BUILDER DECLARAT�ON PtAN CHFCK APPIICANT ��J� —�O
I hereby affirm that I am exempt irom�he Contractor's License ,
law for ihe following reason(Secfion 7031.5, Business and NAME
Professions Cod=�: ,
❑ I, as owner of the property, o�my employees with ADDRE55 .
woges as iheir sole mmpensation,will do the work and
Ihe ttruc7ure it nol in�ended or offered for sale(Seclian pTY TFL NO.
7044,Business and Professions Code).
OWNER
❑ I,as owner of Ihe properfy,om exclusively conliacling
with licensed controc�ois�o consrrocf the p�oject(Sec• ^^0���
tion 7044,Business and Professions Code). /+DDRE55 //"
CONSTRUCTION LENDING AGENCY pT� �f TEI.NO. �vD
I hereby afiirm ihol there is a conslruclion lending ogenty for ►
fhe perfo�monce of Ihe work for which this permit is issued CONTRACTOR .
(Set.3097,Civ.C.). �
ADDRE55 �n.�� , r . . .
Lender's Name � '
pTV TFI.NO.P,'j' �{.�— �,
lende�'s Address ✓ - '
STATE LIC.
I cer�ify�hat I have read fhis application and sioie that Ihe UCENSE NO. �� CLa55 �� - —
abave informolion is covect.I ogree to comply wilh oll Coomy �� -
ordinances and S�me laws rela�ing fo building construction,
and hereby avthorize represeMolives of ihit County to enter � " � � �
upo he ab e-mFntioned property fyy'inspeCtion p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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