HomeMy WebLinkAbout6402AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified Cop th1ere f (Sec. 38 Lab. C.)
Policy No. CF' ompon
Cert. fed copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date l <Applicant ((
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
This seetfon need not be completed if the work involved by
the permit is forone hundred dollars ($I00) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NnT CE TO APPLICANT: If, after making this Certificate of
Ition, you should become subject to the Workers'
C.-.pensotion provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business
and Professions Code,,, {{
lIand
my license is in full forces and effect.
License Number 1 Lie, Class' L
Contractor A L'L.11fe—Dote(9--a—
I am exempt under S.C. JJ
B.&P.C. for this reason
Dote:
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
ro
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the struclure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the properly, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
he performance of the work for which this permit is issued
Sec. 3097, Ci, C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Stale laws relating to building construction,
and h .re y Ihorize representatives of this Co/
Purposes.
y to enter
upon h oSe•mentioned property for inspetn
Signalure of Applicant or Agent D fe
APPLICATION FOR PERMIT z j
76A364C HEATING-- VENTILATING - AIR CONDITIONING 1S
CE - 818 (REV. 10/81)
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN
PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT
ABSORPTION UNIT, BTU
AIR HANDLING UNIT, CFM
BOILER, BTU
VENTILATION SYSTEM
EVAPORATIVE COOLER
FURNACE: FAU A
FLOOR BTU
HEATER: SUSPENDED UNIT_
wnu
Plan check fee
BUILDING AND SAFETY
BUILDING' ADDRESS
PERMIT ISSUING FEE S % c
LOCALITY
FEE
TOTAL FEE
NEARESTCROSSST.
Di51RKT NO. PROCESSED eY
NAME
10 `mc
APPROVALS DATE INSPECTOR'S SIGNATURE
ROUGH
FINAL
ADDRESS
e 8
VALIDATION
Plan check fee
PERMIT ISSUING FEE S % c
TOTAL FEE
PLAN CHECK APPLICANT
NAME
64Q2A
ADDRESS
e 8
CITY TEL. NO.
I••5325
OWNER fAA
LpiL1.. Z
MAIL
e• •55253
ADDRESS I 0403-87403-87
CITY I r, TEL. NO.
CONTRACTOR/ fu
ADDRESS I LT/Y a
CITY TEL. NO._^ (4-q2
STATELICENSE NO. 7 / /1
ASS ( -. ,aniLilCIA.
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