HomeMy WebLinkAbout6071AWORKE'RS'CONWENSATION DECLARATION-APPLICAT ION FOR PERM46T
I h,,'bv affirm that I In— a rertifi-Ic .if consent to self
in -'e, .,a Ccmfic.re of Workers' Compensation I-Itl—e-1 H FATING -V ENT ILATI NC -Al R CONDITIONING
a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company—.—
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is herebv futnished.
C.,Wied copy i, file(] with the c.u.tv building i-PlIzio- F6`F A POCANT TO F LL 1 k; BUILDiNGjj
d spa,tmlnt. D D R E U-20 'S
Date-- app scant ------- i OCAL I T -
CL dTIFIC ATL . Of' EXI, MPTION I -ROM WoRWERS: NO. TYiE 6f.APP LJANCC- OR EQU;-IMENT
P, -iH 1-1 I'DC6MPENSATIONINSURANCEIII -s' T
0Thissectionneednotbecompletediftheworkinvolved7 by the permit IS for one hundred dollars (SI00) or less.) 5f
the
work for which thisIcertifythatit, the P.,fotratme, of AIR HAN151_!N- UNIT, CF1/I
Permit 5s issued. I she!] not employ -Y Pelson many trl,nn,
So a, sabie, I to the Workers' C- BO ICERA, to become mpen. APPR.1-- DATE NISPE,
Date Alplicall &01 1—c—"Esso, RCUGHV
NOTICL TO APPLICANT: If, after caaki.g. this C.,tifi-zc of 'VEN.IL A710N SYSTEM FINAL.
I-eral,xion, you should bCOMC subject. to the Worker,' AL.-
TIDNCompensationprovisionsoftheLaborCode, you .-I lo,t EVAPOSAT W C60LFP. VALIDAI
or this pe,mit Snail bewithc ).ply with ach provisions
deemed revoked. UFINACF: IAI--- CFIAVIIY,
qLICENSEDCONTRACTORSDECLABATION
I herebaffirm that I itly, licensed under provisions of Chap— JAEATER-, SLJ5PF N
9. I WALL
e
ccjn Meftcing With Section 7000) of Division 3 of the Bus,
n " and l'-f—i— Codeand my license 1, in full force a -
effect.
Date
ElI at. exempt from the li"nsiag requirements as I am
licensed —Aarchitectoraregisteredprofessionalevginev, Plan check fee 25% of abGve.
acting in my professional cxpacnv (Section 7051, Sus-
mess and Professions Code) PERILHT MUING FEE 81
Li,.,,, Reg. No. !)at"-- TOTAL FEE
HOME OWNER -BUILDER DECLARATION PLAN CHPCK APPLICANT
Ihe,eby affirm that I an exempt from the Contractor's NMA E -
License Law for the follow ns,. lease. (Section 7031.5. 13-i-
ess and 'Professions Code):
1, as owner of the property, will do the
sale Section
work aced the CITY
tstructurei., not i,,t,.dcd or offered toTE NO. I
7044, Businessand ProfessionsCode).
OWNE,,
11 a, owner of the property, am exclusively contracting
ith licensed contractors to construct the project MAIL ':3, Section 7044, Business and Professions Code). _H .......
CONSTRUCTION LENDING AGENCY
CITY
I hereby affirm that there is a construction lending agency
for the perfor'i ancc Of' the work for which this permit is CONTRACTODR
issued (Sec. 3097* cm
L.,d,r's
L,nde,'sCITY
r .
I certify th't I have read this -j state 1.1-i O'L i TE 'c
1l -
c63aboveinformationis1.elt. I agree To mob, with .11 County I E SE NO-
LT
ordinances Lad State la's regulating Heating. Ventilating and
AilConditionij-, and hereby authorize r,,pre—itatives of this SEE REVERSE 1 OR EXPLANATORY {,ANGUA(,F
County to enter upon the above—mentioned property For
111 "ti0a IMMOle'.
Signature of 11c'mittee Date
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