HomeMy WebLinkAbout1059A NdORKERS'COMPENSATION DECLARATION qpp`ICATION FOR PERMIT
I hereby offirm thot I hove a<ertifimte of consent to self _ g�, �i � b
insure,or a certifimte of Workers'Compensation Insurance, �aA364C , HEE�TING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) �
CE-8181REV.l0ie7) . -
P❑ollcy No.WC51539�Company Uri1g3Y'd IIIS.
Certifad�opy is hereby fomrshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Q Cerflfied copy is filed with rhe counfy buildi�g inspeo- FOR APPLICANT TO FILL IN aw�owG
fion deparlment. (PR:N7 OR TYPE ONLY) ADDRESS
oa�e 5-29-88 APPlimnt ��o Ais, Inc. �ocnurr
NO. iVPE OF APPLIANCE OR EQUIPMEM FEF —
CERTIFICAiE OF EXEMPTION FROM WORKERS' NEAREST �
COMPENSA710N INSURANCE CRO55 Si. n
(Thfs secfion need not be completed if The work involved by A3SORPTION UN:T,BTU csrzi.r xc aectesse�ar
the permil is for one hundred dollars(5100)or Iess.J �
I certify thot in ihe performance of the work for which ihis AiR iinN�ur7G uNii,CF,+n C,y �
permit is issued,I sholl nof employ any person in any manner �
so as to become subject to 7he Workers'Compensation Laws. BOLLER,BiU qppeovni5 ��r: �Nsaecrou�s si��aruae
Date Applicant � COMPRESSOR,BTU �O�OOO $O OD ROUGH �lpJ y��
Nn710E TO APPLICANT: If, afler making ihis Certifimte of VENTIiATION SYSTEM FlNA� rg�
�ption, you should bewme subject to ihe Workers'
,..�npensatian provisions of the Lobor Code,you must forth- EVA70RniNE COOLEe ALIDATION
with romply with such provisions or ihis permit shall be
deemed revoked. FURNACE� FAU_ AVITY
LICENSED CONTRACTORS DECLARATION S F�OOR dTu 8O OO
I hereby affirm ihat I am licensed under provisions of Chapter 9 SUSPEN�E� UNIT_
(commencing with Section 7000)of Division 3 of the B�siness HEATER: WALL - F �
and Professions Code,and my license is in full force and effeU. ` � �"'��' .�-
6 R r 1 } o s o � �g �
License Number 380543 Lic.Closs C-20 �
�
Rancho Air. Inc 8-31-89 � `6�'S� �
Contmcror -0ate
� � �'�Gi:L.JfWc2,. �
I am exempt under Sec. �
e.aP.C.fo�rh�s reason Plan check fee L�°:�6��i% � ,
PERiN1T ISSUING FEE$ 10 50 �
Date:
Signature YOTAL FEE 2( 0
OWNER-BUILDER DECLARATION P�AN CrfECK A�PUCa�VT �
I hereby affirm thot I am exempi from the Contractor's License ,
Law for ihe following reason(Section 7031.5, Business and NAAAE
Professions Code):
^ I, as owner of ihe property, or rtry employees with �DDRE55
t,,,,�.� wages as iheir sole compensation,will do the work pnd CI7V ?EL.NO.
the structure is not intended or offered for sale(Sedion
7044,Business and Professions Code).
OWNER
❑ I,os owner of 1he property,om ezdusively contracfing
with Ilcensed mntractors to mnsiruci the projec�(Seo- �`�`A��
tion 7044,Business and Professions Code1. A�DRE55 1� )} P p `� 1
CONSTRUCTION LENDING AGENCY CiTY TEL. '
I hereby aftirm ihot ihere is a mnslruciian lending agency for ' — '
the performan<e of the work for which this permit is issued � .
(Sec.3097,Civ.C.). CONTRncroe Rancho Air Inc.
ADORESS
Lender's Name
CITY TEL.N
Lender's Address
STATE IIC.
I certify that I have read?his applimfion pnd state that the uceNse No. 380 43 CLASS (,'—Q� .
above information is correct.I agree to mmply with oll County
ordinances and Sfaie laws relating to building construciion,
❑nd reby a�thorize r,�resentatives of this County to eNer �
he above-memi ed property for inspection p�rposes. SEE REVERSE FOR EXPLANATORY.LANGUAGE
—�
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