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HomeMy WebLinkAbout1663A WORKERSGOMPENSATION�ECLARATION APPLICATION FOR PERMIT ��� � I hereby affirm that I have a certificate of mnsent to self'� insure,o�a cerrificate of Workers'Compensation Insurance,� HEATING - VENTILATING - AIR CONDITIONING or a certified[opy fhereof(Sec.3600,Lab.C.) 76A364C CE-RIB(REV.10/81) P�olicy RSs. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. � Certified mpy is filed with the county 6uilding inspec- FOR APPLICANT TO FILL IN eUiLDiNG � �c+�� �^�j J tion depar}ment. ADDRESS �7J �aCr(J�J .r`�jV L� (PRINi OR TYPE ONLY) �ate Appliwnt LOCALITY��n ,/v NO- TY7E OF APPI IANCE OR EqUIPMENT FEE r-r �•� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CRO55 ST. ' �- o (This section nead not be completed if The wark involved by ABSORPiION UNIT,BTU oisraicr No axocFsseo nr the permit Is for one hundrod dollars(SI00)or less.) I cerlify thot in the performance of the work for whith this A�R HANDLING 11NlT,CFM ,� (\�,.., " \ ����n•�.3--, permit is issued,I shall nof employ any person in ony manner BOII.FR,6TU � so as to em e subject fa�he W ker ompensal,on Laws. �n n�aeovn�5 unie w5�•EC1uR'SS�,NqtukE � N`-� Da1e. � � pplicant � COMPRESSOR,B7U Ca� ROUGH � NOTIC O A PLICANT: If, after makiny this Certifimte of VENTILATIDN SYSTEM FlNAI Exemption, you should become svbject to ihe Workers' �i Compensation provisions of the Lobor Code,you must forth- EVAPORATIVF COOLEft VALIDATION j with comply with such provisions or this permit sholl be � deemed revoked. RJRNAC[: FAU ��AVITyl� {^ � LICENSED CONTRACTORS�ECLARATION FIOOR BTU �� � �,[� � I hereby affirm ihoi I am licensed under piovisions of Chapter 9 HEAiER: SUSPENDED UNIT_ �([ommencing with Section 700D)of Division 3 of ihe Business WA�� ❑nd Professions Code,and my li<ense is in full force and effoU. � 4. �ry z u j'� I c� �� 3 '�lfi' , p License N ber,34r� .)� Lic Clas�" �`= � Contraclor � ^J DateS__�� � � W I�m exempt under Sec � Picn check fee � ' B.BP.C.for ihis reason PERMIT ISSUING FEE$ ��}, (."1 � Date: TOTAL FEE �''" Signature - OWNER BUIIDER DECLARATION vLHN CHECK APaLiCANT � I hereby affirm thdi i am ezemp�from the Contractor's License ► Law for ihe following reason(Section 7031.5, Business and � NAMF ProfessionsCodef. �,, ❑ I, as owner of fhe proper'y, ar my employces �.Nith �DDRESS � ! `������ wpges as their sole mmpensation,will do the work and '� ��' the structure is not intended or offered for sale(SeUion Ciiv TEt.NO. a . � 704Q,Business and Professions COde). + � �' i :i i�;C,� OWNER L��Y Lti..� , � n a ry ❑ I,as owner of the p�operty,pm exdusively contraUing . �.� with licensed coNroc�ors to consiruct the projeci(Sec- �'�'���- .-? _� (p f� �r� . tion 7044,Business and Professions Code). ADDRE55 `J-� -�r�g.l•� 4 S;j CONSTRUCTION LENDING AGENCY ❑TY � TEL NOG' , �� G p�g I hereby affirm ihnf ihere is a mnsiruction lending agency for the performance of rhe work for which this permit is iss�ed CONieaCiOa I 3' , (Sec.3097,Civ.C.). nooRrss ��y ` � . Lender's Name CITY � TEL.NO � Lender's Address STATE LIC. I ceriify thaf I have read this application and state thot the UCENSE NO. CLA55 � - above information is correct.I agrce to comply with all County ordinonces and State laws relating to buildin�consiruction, hereby nuthorize representatives of ihis County to enter p n � a �e menti ned property f insp ctlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '� Sig rure of Applicani or Ayeni Dara �(( , li . � i i � 1 I �1 � � � � A� , �� i � a � I 0�� �i � � i I 1, � � a � t � � � I � I � � ' I � ` I ; � � ; , , � , � f � � , ' �, , , ' � � ' ' '�' � , � , � � , ; � � � I � � 1 ; i i { I � i � �! 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