HomeMy WebLinkAbout6402A (18)WORKERS' 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 ($100) 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 1Lie, Class L
Contractor A /
J
Dot.-
I am exempt under S.C.
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 structure 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,
andrelly Ihorize representatives of this Co/
Purposes.
y to enter
upon h oSe-mentioned property for inspe ti
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 . FEE
ABSORPTION UNIT, BTU
AIR HANDLING UNIT, CFM
BOILER, BTU
VENTILATION SYSTEM
EVAPORATIVE COOLER
FURNACE: FAU A /
FLOOR BTU V
HEATER: SUASPENDED UNIT_
IM
Plan check fee
PERMIT ISSUING FEE S JIV C
TOTAL FEE,
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
OWNER
CITY JfA 0 6,_TEL. NO.
CONTRACTORfuFu- iA
ADDRESS
CITY
STATE( n
TEL. NO.
n (
4-q '
LICENSE NO. ( y f CLASS
SEE REVERSE FOR EXPLANATORY LANGUAGE
BUILDING AND SAFETY
BUILDING _I
ADDRESS 6I
LOCALITY
CRO55 ST. CROSS ST
CROSSST
Ci
DISTRICT NO. PROCESSED BY
APPROVALS
ROUGH
FINAL
u
10.
DATE INSPECTOR'S SIGNATURE
VALIDATION
6402A
e 8
1••5325
e••53253
0303-87
Fli I- \ } (x:3
a— a6y2k?;/[»J
R[k§ƒ\E§j}////} j}/
q 2]/§gE 7n}w{®m`;m, 0
s E-®±;}%\R[=2f%&(\/2\~27m}
E.
27\|(;-2E= 0§Q-3-oZ7 5o
aC,11 CL/,q\k{/ q:\®)'k§f°
ARG°®[&- i§Cl.0 3I
E[$[G[(}
2!®!&ea
g
4(\(k
o_-
e
momƒ;;E?=»°;,_
CO.
cc
f{%!
0-°22[y°.2% ice«/'Q2\fewj\\\g;;a%§2}} 2}@\(\±f}m2
Qo2
oa; Sa:nJ,a
10 a Rn o
0
0§/\\/
q E¢.f
0 r-\ %,
kyC:
7-2.t)
Fli I- \ } (x:3