HomeMy WebLinkAbout1663A (225) 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
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