HomeMy WebLinkAbout1061A � N�ORKERS'COMPENSAT�ON DECIARATION . .. . . . � � �� APPLIGATION FOR PERMIT .P� E'
I hereby affirm that I have o certificate of conseni to.self �ji p9
insure,or a certificme o4 Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING �
or a certified copy thereof(Sec.3800,Lab.C.) 76A36aC
CE-818(REV.70�811
Pr,ollcy No.�'1CS1rJ39�Company Uni�ard Ins.
L� Certified capy is here6y tum�shed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the munty building inspeo- FD(t J,\PP��C/�NT j�F����N BUILDING
r�on deparimenr. ;PRiNT oa rvae oN!v; nooaess Q1�216 E. S lvan Glen Road
Dote 5-29-87 qPP�;�o�r �nch0 Air. Inc. � iocAurr _
' ND. TVPE OF APPLIANCE OR EQtJIPMENT FEE
CERiIFICATE OF EXEMPTION FROM WORKERS' NEnRE51 •
. COMPENSATION INSURANCE CR0555i
ABSORPT!ON UNIT;8TU DlSraiCr No. �ROCE55Eo a�
(This section need nof be compteted if the work Irtvolved by . ,
fhe permif is for one hundred dollars(5100)or less.) qig Hq��p�iNG uNl i,cFM �fl ��
I certify that in ihe performance of the work for which this . ._... _.,,,.,.
permii is issued,I shail not employ ony persan in any manner
so as ro become svbjecf to 1he Workers'Compensation Laws. BoiLER,eiU arvxo�'A�s onre iNsc �oas s!Gnqr�aE
Date Applimnt COMPRESSOR,BTU 30���� i ROUGH
fa�'�jICE TO APPLICANT: If, pfter moking this�Certificate of vENTRAT;ON SYStenn FiN/+�
f �plion, you should become su6ject ta the Workers' , '�
�_.npensolion provisions of the Lobor Code,you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such pravisions or ihis permit sholl be
deemed revoked. FURNACE: FAII_.GRAVITY
LiCENSE�CONTRACTORS DECLARATION FLOOe B7U �
I hereby affirm that I om licensed under provisions af Chapfer 9 HEATER� SUSPENDED uulT_
�(commencing with Section 7000)of Division 3 of rhe Business � WA�- -`;� J�� p
ond Professions Code,and my license is in full force ond effe<t. � ' a'
56 �iegisters @ 1.75 98 00
i��e�se Num6er 3805�+3 �,�.cias5 C-20 �`° � ° ° °g �
�
Contractor RanC�o A].T. IIICbo�e 8-3?—89 , + °%��5� �
❑ � � �
I om ezemp7 onder Sea `�6•;i�G� �
Plcn check fee �
B.&P.C.for rhis reason ��G G='�7 �
PERMIT ISSUING FEE a 10 0 —
oate: 80TAL FEE 268 50
Signature ,.
OWNER-BUILDER DECLARATION N�AN CHEIX APP:iCANi
I hereby afflrm thal I om exempt from ihe Contractor's License � ,
Low for fhe following reason ;Section 7D3L5, Business ond NAME �
Professions Code): � -
��l I, as owner of ihe property, or my employees with ADDRESS
woges as iheir sole compensation,will do the work and � � � �-�- """� "�'- ���-"" �"
the siru<ture is not intended or offered far sale(Sec+ion CiTY TEL,NO.
7044,Business and Professions Code1. �
OWNER
❑ I,as owner of the properly,am excluslvely contrading
. with licensed contraciors to construct 1he projecr(Seo MnIL
tion 7044,Business and Professions Code1. ADDRE55 ��7� P�'gV1QW Drive �{2�l
CONSTRUCTION LENDING AGENCY ��T� (,`OV1II8 tE`�N��18) 967-95�+1
I hereby afflrm thai}here is a cons}ruction lending ogen<y for ,
.. . ......._ _.. ...
fhe performance of fhe work for which thls permif is issued CON7RACTOR
(Sec.3097,Civ.C.J.
ADDRE55 c
Lender's Nome __
Lender'sAddress ��T� laIId TE��lk� gsl—�F$Ol
I ceriif that 1 hove read ihis a licotion and state that the STATE ��UC. ' '�' � ' '
y pP LICENSE NC. I�. CLASS C—ZO
above�nFormotion is correct I agree to comply wi�h all County � - � �
ordinonces and Sfote laws relatinq to building cons+rucfion,
ond reby authorize epresentatives of this Caunty to enter
up he above-ment oned properry for inspection purposes. SEE REVERSE FOR EXPLAN.ATORY LANGUAGE
� � ' �:������7
s�3„m� or nP�n�a��o,nn` oa�e
INg���F�R'�6���@S dNlN�2-5iJiLUE�[3ECLAo-2ArtibN
� hereby a*t�rm*I„I c ^xemai irorn th3�ont•aclor's
Lir.en;e Laa� ��ur the f,l•.owing r.. . i5ccfion 7431.5
- Buslness anG Frof=�s�crs Ceda1-.0.,ry ci?y or�cunry whi<h
- -- � � requrres a parmi7 Pe c ,-��ruct,�Itcr.;ropreve,dumoi�sh,
- or�eperr er,y 57i'JCi'UfC,y(JY%Of 'ro i?- issucnce, clso r=-
- quires fh3 appli<ar4`or soch perml;10 fi!c�o signed sto;e-
rnonf tnet he is!ice.�sed pursuur,9 to rhe pro�ision,oi t,4�
� Contrecfor"s L,'cense Lrny(Chopfe%Y'commeacrng�rith
� � Sec, :7GOu�of llivision 3 or she�usiness a:�c'Yro`as-
`- ns Coo'e)cr tha'he is exa.np7 fnerafrom and the bcsis
9or 'rhe al!cyed c empiiun. An� vioioPicn of Section
- „7031.5'uy aay cop,'cant.fo�a p�rmit suSjncis the appli-
cart7 7o c civil o�nal7y?f not more fban live hundred
... . , doilors��SuL',i.-
� � � . � � � . � � as c �. %iha prope�ey>..II oc ti,e�+,c-k cn.�
� ' � ' � ihe siructura:s�:w rlr crced or oi{ered for sala.
' - . . . ... � �$BC.7O�S�S,BU51.iE55 ORfI FTO�ESSIORS COG�G: TFi+9�'~'CC-
_ � tor's i.icensc Lcw doe::ncf cpy!y to an owner of p. rrSy
v✓ho builcs cr rrnprcves ihereon, and who dces sur.h
�----- --""—. , ""---"`--- or4 h aN p:cvided::;ar such improvemer.ts arc not
m;and�d o;ofPerca'Por sale.I(,hnwever ;he 6i,ilcin,er
� ---- improvemenl!s sald wi?h.fi orr_yeo�of compleFion,tl��
, �� � � owner-buiJder will h�ve fhz 6ueden ef provir.g ihoi he did
rot hu'rld or imprave�for ths purpese vf=ai�.)
_ ___ ___ � ❑1,os o�vrer ot tne property,ar,exc!usivaly cen-
nactinc vaiih lic�r.sed contrcctors to:onsi•ccr ttiT prc;cc
�jsc.7044)Susiness and'Yro�essior,s::c:ie.�h=Co.�7:+;c
� tcr's License l�w dacs noi app!y;o ca osrr,er oi pre��erty
�v6o b✓iids cr improves 4hcremi,ard wno c .racts fcr
sur.h orojecfs with a contracfor(s)iiconsed pursuar'fo
}he Cor,'rac`or's Liccr,sc[vwi.
I cm exempi under Sec.__
B 8�P.C.for inis;ecson___.__—
Date
--- Q�vner�
lPPSPEC7�+�'S PEA3ES