HomeMy WebLinkAbout1682A (225) WORKERS'COMPENSATION DECLARATION qpp��CqTION FOR PERMIT � �
1 hereby affirm ihat I have a certificate of consenf to self
insure,or a certificote of Workers'Gompensotion Insurance, ��� HEATING - VENTILATING - AIR CONDITIONING
� or a certified copy thereof(Sec 3800,Lab.C.)
aY Pwc o5061� P Y T.,�,� CE-818(REV.10/Bt)
Polic No. m an Golden u.sle Ins.
Certified copy is hereby f�rnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUIL�ING
fion deparfinent. (PRINT OR TYPE ONLY) A�DRESS 24 Y' �-0.p C
��,��TY �,o�r# 16 .7ob� 876
Date 5�2�a9 qpplimnt RAnPhn A�T_ Tnr_ NO. NPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' �Ro�SST D18IDOA(� BS'C Tract� 42582
COMPENSATION INSURANCE
(This�oNion naad not ba compl Wod if 1ha woric Imolved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
The'prrmif i�for one hundred do{{uri(SI00)or lau.) q�R HAN�LING UNIY,CFM
i cerlify ihat in the parfo�monce of the work for which ihis � lD �Q G��
permit is issued,I sholl not amploy ony parson in any manner gpILER,B7U
so os ro bemme subject ro the Workers'Compensation Lows. nwRovais DAiE INSPECTOR'S SIGNATURE
Z COMPRESSOR,BTU 3 fOOO PO OO gpUGH
Date Appliwnt . ��
NOTICE TO APPLlCANT: If, after makin4 this Certificate of yENTIL4TlON SYSTEM FINAL L��c�
�xemption, you should become subject to the Workers'
� :ampensotion provisions of the La6or Code,you must fiorth- EVAPORATIVE COOLER �/A�IDATIDN
` with comply with such provisians or this permi�shail be
deemed revoked. 'Z Fu�CE: FA BT��4��� .� 00
LICENSED CONTRACTORS DECLARATION
t hereby affirm fhat t om licensed under provisiom of Ehapfer 9 HEATER: Sl15PENDED ��NIT_
�(commencing with$ectio�700Q)of Division 3 of ttw 6usiness ' W'0`«
and Professions Goda.and my license is in fvil fwce and effect. ],5 $p,glSte2'S � 1.75 �a 26 25 z� E�i H �
3805�+3 �
License Number lic.Class C�20 � U
r•s • o a k O
Cantrottor �cho Airz ZII�Q�e 8-31-89
r
❑ I am exempt under Sec. plan check fee ' • •7� / ` N
B.BP.C.for thia reoson � ' "�' �� �` x
PERAAIT ISSUING FEE S 10 50 �, � Z
Dare: TOTAI FEE 76 75 � � 2 C—�'
Signoture
OWNER•BUILDER OECLARATIQN MAN CHECK AV7LICANT
I hereby affirm tha�I am ezempt from the Cantroctor's License �
Low for the following reason(Section 7031.5, Business and NAME
Professions Code): •
f ❑ I, as owner of the property, or my employees with
ADDRES$
� wages as iheir sole compensation,will do the work and �� 7EL NO.
� the shucture is not intended or offered for sale(Section
7044,8usiness and Professions Code). OWNER •
The Anden Group
❑ I,as owner of�he property,am exclusively contracting
with licensed coMractars to cons�ruct the projett($eo- ��� ev �Ye `�1
fion 7044,Business and Professions Code). ADORESS �
CONSTRUCTION LENDING AGENCY ��Ty FJ�' COYlIIB� TEL.NO. Sll,r-9 -954i
i here6y affirm�hot there is a conslruction lending ogency for ,
the performante of the work for which ihis permit is issued �ONTRACTOR �'�0 �R� �C.
(Set.3097,Civ.C.).
ADDRESS ]_23'2 tiJ. qth 3treet
Lender's Name
CITY l�d. TEL.NO. _ _
Lender's Address STATE UC.
I certify that I have read Ihis application and state 1ha�the LICENSE NO. CLASS _
a6ove information is carrect.I agree to comply wiih all Co�nty
ordinances and 5tate lows rela�ing to buifding consiruUion, .
and hereby au�horire represeniatives of this County to enter
upon th ab ve-menrian d property for inspecNo�purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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