HomeMy WebLinkAbout1063A � N�ORKERS'COMPENSATION DECLARA7ION APPLICATION� FOR �PERMIT �
I hereby affirm thot I have a certificate of consent fo self /�JJ� �
insure,or o certificate of Workers'Compensation Insuronce, r�"
or a certified copy Ihereof(Sec.3800,Lob.C.� �er+35qc HEATING - VENTILATING - AIR CONDITIONING .
�ac5�-539� uni ard `E-8,g'RE�.�o,e,;
P❑olicy No. Company � ��• . ' . . .
Cernfied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
,_. _:..::... ..... . ._ ....
_ .... .
� Cerrified mpy is filed with the counfy building inspec- FOR APPLICANT TO FICL IIV eUuowG
tion deportmenL ;pk�Ni OR ivPE ONLvI /aoDRE55
Date 5-29-87 APPlicom��o �-r, �• � . � - iocaurv _
NO. TYPE OF APPUANCE OR EQ�IPMENT FEE
CERTIfICATE OF EXENiPTIOMFRONi UVd'RKET£5'"�- � NEARES7
COMPENSAifON INSURANCE� �� �� CR0555T.
(This secfion need nof be compleTed i1 fhe work involved by %BSORaTION UNii,BiU oisTe:a�ue PROCESSED BY
fhe permif is for one hundred dollars(S100J or less.)
I certify that in ihe performance of�he work for which ihis A�R HANDLING UNIT,CfM �� ��
pe�mit is issued,i sholl not employ any person in any mpnner gp;LER.BTU
so as to become subject�o the Workers'Compensation Laws. nPaaovtiis � onr insP roes si�rcnruee
Date Applican� 4 COMPRESSOR,eTU �O OO ROUGH
�TICE TO APPLICANT: If, ofter making�this Certifimte of vEN71LAT�ON 5vS7EM FWAL ��
'iption, you should become subjecl to ihe Workers'
�,.�npensotion provisions of�he Lobor Cade,you musl forth- EVAPORAT�VE COOLER �/ �I�AT��N
with comply wiih svch provisions or �his permif sholl be
deemed revoked. FURNACE� F.4u�G VITY' '
LICENSED CONTRACTORS DECLARAiION �d F!OOR BTU ZVO OO
I hereb ffirm ihal I am li<ensed under rovisions of Cha ter 9 SUSPENDED L'NIT_ �� Q��
Y° p P HEAiER: waLC
�(commencing with Sec�ion 700D)of Division 3 of the Business
and Professions Code,and my license is in full force ond effed. 1 e.I �9, (} �
License Number ZR(1S1�� Lic.Cbss r.—�n , d ^ ' .;�,�Q` 6�)
�
co�r�acfo�Rancho I�ir. Zncoare A-31-8�_ u o��—8 7 �
❑ I om exempt under Sec. �
Plan check fee
B.&P.C.for this reason � �
PERMIT ISSUING fEE S. �
Dote:
TOTA!PEE 13 0
Signoture
OWNER-BUILDER DECLARATION PLAnI CHEIX APPUCaNi
I hereby affirm that I am exempt from ihe Cantrador's License �
Law for ihe following reoson (Section 7037.5, Business and NAME
Professions Code):
��A� I, as c er of�he proper!y, or my employees N-ith ADDRE55 �
wages asnrheir sole compensa��ion,will do the work and
'he str�cture is not inlended or offered for sole l5ec+ion ciiv TEL NO. .
� 7044,Bcsiness ond Professlons Code;.
owNee �ye �uden Gronp
❑ I,os owner of rhe property,am exclusively controcting
wirh licensed contro<tors to mnstruct the projec�(Seo MAu
rion 7044,8�siness ond Professions Code). /DDRE55
CONSTRUCTION LENDING AGENCY CITV (,`OyiIlg ?e�.No. (gi8) 967-95 1
I hereby affirm ihot there is a mnshuction lending agency for ►
the performonce of the wo�k for which this permit is issued CONTRnCiOR ganeho A1T�ZIIC.
(Sec.3097,Civ.C.).
/+DDRE55 1232 W• t� Street
Lende%s Name
CITV TEL.
Lender's Address —
STATE p a� LIC.
I cerrify�hat I hove read this application pnd state that the LICENSE NO. �pOS'tr3 :La55 C.-2�
a6ove information is correc�.I agree ta comply with all County
ardin ces and State lows relotiog to building construction,
and �ere6y auihoriz representatives of this County to enter
u the above-me rio e d p�operty for inspection purposes. SEE REVERSE FOR EXPLANA70RY LANGUAGE
� �a����
S�pna re of Appl,�ant o� Do'e
_ . . {N�P6G'P4?�'�TEpY�S . ' ATI,OiV
O NEP- UI�. �t
, I here6y aff;�m thct I�2 _ noi f� m fnc Contractor's
, � � � . ^ �i-.ense low fa� iFe fcllow ng rcoson (Sedton 7031.5.
.'. .. � . Eu,lness ortd Prci'.:.siors Code;:t;ny�ri4y or mun:y,��hi=h
.. . . .,.........,,.. .—_— . : requir.s c permit fc,c<.ne.trucf,cii�r.im,�ro�,da�ioLsti
' � or repa:r ony s4ruc9�•:e, pricr Pc its istuonc2, alsu re-
� �'quires+F,e applicar.t fcr such pemiYto f%ie n signey s!c'e-
��� � men9 rha4 ha is!ir,-srd�u�suan6 to ihc prcvisians o4 rne
. Ccn9,ocro%s License Lavr(Choptar 9 jcc,mmcr,rr,y wi!h
� � - � � � Sec� n 7000j of uivisicn 3.-.f;nc Bcsiness end Pro:as-
. — � ' sions Ccdel or:hei h=is<�se;np;t:ierafrorrr and;hc Sosis
For tl�a cllcgcn e empf!cn. s'.ny v - of�Seciion
— - - — � 7031,5 by ony opi licontr for p parmR�uSjects rna cppfi-
, . , cant ta a civii penak�nf nof morr ihan.i�ve fiundred
, . . —' dc'!crs;SS�:�i.� .
- �� � ❑L o.=c:me•r cf thc propertq v���d do fha�..c!<.a�d
� iot h ended or offerad ior sa!a.
.. . . . c.•704:r8usincssand�rafc,sions�Rc�e:,The�� -
� . . - or s Lic.^-.nse Lovr does not app!y to on o c:o`p. rrty�
who Suifds cr imprnves.�ha;ean, �nd vnh� doEs such
� ---,--- —' wer!c nim�sl4 pro.'rded ihvr sucn improvemznts are nor
. ��:icnded or offared fcr sale.14,i� ���er,Ih^�uil��ing or
ow^
, . . .:...:.:.....:.
�� � ,,:imprcvemen3 i;sold v✓isnin ene;�eur cf cen,p,lePiwi,1i`e
' � ownc^boilder wiil bpv�a iha burdan cf p;oving+noi L�dio
� noi oui!d o:imorove for ine purpose oF sale.j
._____.. __' _ ❑I,as oavncr ci tna�ropeny.�r;exclus.ve!y mn-
� 'racting vditn licersec confrac7cr<ro con=ln:c`fhc,:rc;cc•
__ _ __ $cC.7l4/;)uf151'1255 6l�CI Prpic^5�16(15 CLd.^,'I�L`�O,-�+�OC-
-'s Lrcer.sa Lcvr do�s noi app1�fo on o��r,^r�o1 p,-operty �
who bc!!ds er impr✓es;her2on,ortd tyno conf�octs se;
� � � such projec4s wi!h a ccntroctor!s;irc,.riszd purs..mil �o
_ _ _ the Cor.`radar's Lic�r.se Cow,%�.
. .... .. . ..._._.. .. _...._..__.__._... .
. _. _ _ . . _ _ _ ..... ..
_. I am exempt under S::c.____ ___.__- ___
�— B&9.C.far ihis reosan
. -- — Date.�----------------
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INSP5CT4R'S P407�5 .