HomeMy WebLinkAbout1062A . Vt�ORKERS'COMPENSATION DECLARATION APPLICATlON FOR PERMIT /� �
I hereby affirm ihat I have a certlficaie of consent to self , �,yL� �
insure,or o cerfificote of Warkers'Compensafion��s�ra��e, �bA3sac HEATING - VENTILATING - AIR CONDITIONING �
or o cer7ified copy thereof(Sec.3800,Lab.C.) �
CE-818�REV.10.81 J
��YNo. WC51539�camPa�y Uni�ard Ins.
Certified co is hereb furnished. , ; BUILDINCi AND SAFETY
av v r...;:- ,., ,. ,... COUNTY OF LOS ANGELES
� Certified copy is filed with ihe county 6uilding inspec- FOR APPLICANT TO FILL5IN eu'���N�
tion department. ;PRINT OR TYPE ON!V) A�DRE55 21L'�].O E. S IV
5-29-87 I�-i.cho Air, Inc. " �oca��rr
Date Applicant
NO. TYPE O�APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
� COMPENSATION INSURANCE CRO55 57.
(This secfion need nof be complefed if fhe work involved by !�.g�.RP7iON,UNiT,BTU o-,s�eicr ve veecesseo 9v
fhe permit is for one hundred dollars(5100)or less.)
1 certify fhat in ihe performance of the work for which this .AIR HAN�LI,NG,UNIT,CFM� �� a �
permit is issued,I shall not employ any person in any manner gOILER,eTIJ
so as io become subjecl to the Workers'Compensotian Lows. :,Pavovns �nre i�s�crox�5 scr�nTuae
Date Applicpnt � roMPRE550R,BTU (}Q � ROl1GH Y��� ,.�,F��7 �d'�
N'�TICE TO APPLICANT: If, ofter making rhis Certificote of vENi��qiioN SvsreM� F�vq� � �p
' �ption, yo� sho�ld become subjed ro the Workers' �
�.:npensation provisions of the La6ar Code,you must forih- EvaaORaiivE COo�ER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNaCE: FAU_GRP,V�TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm ihat I am licensed under provisions of Chapter 9 HEaieR: SUSPeNDEo uNiT_
(commencing with Section 70D0)af Division 3 of the Business wA��
and Professions Code,and my license is in full force and effeci. �'
28 Registers � ]_.75 �+ OO �1 0 6.2 F a
License Num6er 380543 Lic Closs C-2� •, �
''' '8 rm
ContrdcrorR�IIC}l0 Air, ZIIC pa�e S-3i-89 � 7 �� 5�,v� �
❑ I om exempt under Sec - � � -; z� - x 'u�+
Plcn check fee ` � �- . �ti� �
B.&P.C.for this reason PERMIT ISSUING FEE s 1 _
Date: 5� ����.C 4J��d / �
Signature TOYAL FEE
OWNER-BUILDER DECLARATION PLFN CHECK APPLiCANT
I hereby affirm�hat I am exempt from ihe Contractor's Gcense � ►
Low for rhe following reason(SeUion 7031.5, Business and NaMf
Professions Code):
^ I, as owner a{ihe property, or my employees wilh ADDRE55
�.� woges as iheir sole compensation,wlll do ihe work and CITv TEL NO.
ihe siruUure Is nof infended or offered for sole j5ection
7044,Business ond Professions Code).
OWNER r�e rinden Gro
❑ I,os owner of the properiy,am exdusively cortracting
wi�h licensed<onhactors ro construct the p�oject(Seo- '�`�'A�� _
tion 7044,Business and Professians Code;. ADDRESS
CONSTRUCTION LENDING AGENCY Ciiv iEL NO. .
I hereby affirm thot ihere is a construction lendinq ogenty for _ —
the performance of ihe work for which ihis permit is Issued CO'�vienCiok Raneho �ij.2'� TIIC. ,
(Sec 3097,Civ.C.). �
ADDRESS tre t
Lender's Nome O�
Lender's Address ��TV T `+ �--4 Ol
STATE LIC.
I rertify that I have read ihis application and state that the LICENSE NO. CLA55
ahove information is correct I agree fo comply with all Counry
ordinances and State laws relating io building consruction, .
and ereby authorize representatives of ihis County to enfer � '
the above-men oned property for inspection purposes: � SEE REVERSE FOR EXPLANATORY LANGUAGE
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