HomeMy WebLinkAbout1064A . 10!ORKERS'COMPENSATIONDECLARATION � APPLICATION� FOR PERMIT �
I hereby affirm thai I have a certificate of consent to self � �
insure,or a cenificate of Workers'Compensation Insuronce, �6A364C HEATING - VENTICA4ING - AIR CONDITIONING .
or o ceriified copy fhereof(Sec.3800,Lab.C.) CE-B1B;REV.IOi817
.P❑olicyNo.WCr71S39Z4Company TTnigarr� T]y5 . - .
Cert�fied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
,.. - ,..�,..,..;. .. �. , „_ , �„;..
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� Ce�tified copy is filed with the munty building i�speo- FOR APPLICANT TO FILL IN eui�o�!vr,
tion departmenf. ADDRE55 `��
� lPRlh'T OR TVPE ONLYI
5-24-57 •
Date AppllcOnt �O P�I,Y', TI]C. . �. . .. -�� �OCALITY _
. :„�...,.0����.,�•�•. NO TVPE OF APPI!ANCE OR EQUIPMENT FEF ' '
CERTIFICATE OF EXEMPTION'FR�bM VJORKE�RS' -�� � �� NEAReST � °
COMPENSA710N�INSURANCE . CeO555T. 1T2,Ct 14 (
(This secfion need nof be completed if fhe work involved by ABSORPTION UNIT,BTU �i=_rx;C•NO. PROCf55ED 6Y
The permil is for one hundred dollare(S100J or less.) �
I cerYify ihai in the performance af fhe work for which ihis AIR HAN�LING UNIT,CFM . ,2
permit is issued,I shall nof employ ony person in any manner gpILER.BTU ��
so os to become su6ject ia the Workers'Compensation LOwS. qpPRO�AiS �nre insaecToe�s s:�n�nruae �
Date Applicant y COMPRESSOR,BTU ROUGH
pl7jICE i0 APPLICANii If, ofter moking fhis Certificdte o` VENTILATION SVSTEM FWAL ,
� �plion, you shoutd become sub��ed to ihe Workers'
_.npensotion provisions of the Labor Code,you must farth- EVAPORATNE COOLER V LIDATION
with comply with such provisions or this permif sholl be
deemed revoked. FURNACE� FAU_GRAV!1Y
. LICENSED CONiRACTORS DECLARATION �} FLOOR siU _�i �(y(�A
I hereby affirm thal I am licensed under provisions af Chapter 9 SUSPENOED UN!i^
�(mmmencing with Section 7000)of Division 3 of the Business HEATER�. �vA�� �a-t+ o o s R
and Professions Code,and my lirense is in full force and effect. 9�
2S Re 's ! Q 1 �9.50 °'
License Number 3�05�+3 Lia Class C-9n �
� e .: ; �y.sr� �
Controctor R�.IIC�'30 Aar_ Inma,e,_R—�1-R9 Z`j
� G8.2o--�;7 �
I pm exempt�nder Sec.
Plcn check fee a'�.
� B.&P.C.for this reoson �n
PERMIT ISSUING FEE S 10 50 �
Dote:
Sig�otore TOTAL FEE
OWNER-BUILDER DECLARATION 7LAN CHECK APaL'CANT
I hereby a`Firm�ho�I am exempt from fhe Conirac�or's License ,
Low for�he following repson(Se«ion 7031.5, Business ond NAME
Professions Code):
!'�� I, as owner af fhe property, or my emplayees wi�n A�DRE55
wages os their sole compensation,will do ihe work and ��iv TE�.NO. '
the structure is no±intended or offered for sale(Section
7044,Bus�ness ond Professions Code�.
❑ I,os ewner of the - OWfJER
prope�fy.am eudusrvely mnirocting MAIL
wilh licensed contractors to construct the projecf(Sec- qDDRE55
tion 7044,Business and Professions Code).
CONSiRUCTION LENDING AGENCY
I here6y pffirm thoi ihere is a consiruc�ion lending ogency for C�TV Covina TE�. — ►
�he pertorman<e of hhe work for which this permii is issued COUTP.tCioR � � �-��� �
(Sec.3097,Civ.C.1. RaSI
ADDRE55 1•� •2 w� �
Lender's Nome
C!TV 7EL NO
Lender's Address
STATE LIC. �
I cerfify fhaf I have read this applicaiion ond stafe thot the ��cENse No 3805�+3 C1A55 C.-2�
above information is correct.I agree to mmply with all Counfy
ordinances and Stote laws relafing to building constru<tion,
and hereby authorize representatives of ihis Coonty ta enter �
u on the above- ennoned properry for i spection ppurposes. SEE REVERSE FOR EXPLANATbRY LANGUAGE�
d i7l(�'�7�
S�gno re o4 Applicant or�ge r � / Dnre
�w���re����w�z�s ovd����-�u�+c����c�a��aT�or�
i hcreby afYlrm tnol.l om�xampt trom ihE Cor,�;c<Ic-'a
� . — Licensc ; ior :be fol!owiog r ., n (Sc<tion 7G'13
' . ,. ' - Business and Profession=Co�cl::,�ry�i!y or counrg which
-- --� `. .... . . —�—u--i requlres cpsn,i!fc constuc?.alPer,impro4e,�dcmoli;h.
� " �__i_�`_ or rcpair cry sPru;tura,priar"o iis issucnce. olso re-
� , ,.. quires f(ie app;ican!far sucfi,�ermit to 4ile a signed s`ets-
� ment ihpt hc is fieensati par,uant fu yFe Nrcvisions ef Ibz
�, . . ~— — conrrccror's.ticcnsa L w("c6opt•sr S(rcmm,ncing vr;rn
� Se<tion 7900j of Givi;an 3 0`1he Business and?rofss-
sions Ccdzl or fhar he r,ex:;rnp:eierefrom cnd fne uasis
� £or f6a a!!aged ezamp;io.-�. P;rry vf;�otien ct Sec+ion
� — — — —� — 7Q31.5 by any a;�pf7ccni`or o permir su6jects ihe oppli�
car.t:o a civil penoli:;of nof inere ihen (ivo hundrea
. . - . - dolla.-s(S3PO,L�
�.. .. . . � � � _:I.�.s o�::nc=r c:t�.a properl,;.,, ,:dc 1'na�.w.,<..,i_
_ _, , — — �i,,c,:ructure is not In'�enced or cf:ered fer scle.
� - � � !Sec.3044,B✓sittess an�c??rofessions Code: ihe�"��ac
tor's iicensc Low do=s nof apuly Fo cn oa+n�:of p =rty
. N�':o duifds or improves f6ereur., ond�mho does such
� ... . --:—; .--- work';irn�elf Nrovio'ed tSef s;:ci�vnprovements are not
- � �nlended or of!cred fur sale.If,'<ev�ev�;.tbe buiidir,�cr
� - improvemsnt is scld within eno yeor o7 campletion.th^
� owner-buiiderwi;lhcvetheburdenofprovinylhaiFedi�
�� noP 6uild or irn�rove�for fbs curpose Af scla.)
. __ ..__ ________ ❑i,as cvner ot ihz property,a.. ;esively con-
.. � - 'hacicg mi°h liconsed coni•ac�ers to cons�.�ruct tl��project
_ 'Sec 7pS4;Sus �nd p,roqes;iors C000:'��,e Corlroc
for's Li:erse ta�:does r.of cpply'o r owncr cf p=oper
___ who builds or improves thzreor„cr.d who confrq:ts£cr
� such prajecfs wi46 n coniractor!;1 licensed punucrt�!o
, fhe Con"rctFors t.iaer,sc Aarv;. �
_� _ !cm c;xenpt una'er Se[.__— __'__
B&�'.C,for t,h.is�rea;or_�__�-�� �� � '
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