HomeMy WebLinkAbout1664A � WORKERS'COM7ENSATION DECLARATION � APPL'CATION FOR PERMIT � �� ��ryqq��'
I hereby af{i�rm that I have o certificote of consent to self �
insure,or a cer�ificare of Workers'Compensation Insurance, ��36nC HEATING - VENTILATING - AIR CONDITIONING
or a c�riified wpy thereof(Sec.3800,Lab.C)
CE-818(REV.10/81)
Paol�icy No. Company
Cenified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county building inspec- FOR APPLICAN7 TO FILL IN BUILDING .. � � ,� -�
tion department. ADDRE55
(PRINT OR TYPE ONIY)
Dote Applicant LOCALITv
NO. TYPE OF APPLIANCE OR FQUIPMF.Ni FEE
CERTIFICATE Of EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. F� �� .
A6SORPTION UNIT,B�U
(This secfion need not be completed if fhe work involved by nisruiu No i�uocesseo ov
}he permii is far one hunflred dollars(�100�or Icss,� AIR HANDLING UNIT,CFM
I certify Ihal in the performance af the work for which ihis i�I ^��� �-.,.
permit is issued,I shall not employ ony person in any manner ;
so as to em e subject to the W e � pensation aws. sonee,aTu nroenvAu nnrF r i'sarcioa-s;i�Nnruer
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Dote Appl icanf ' �1•l COMPRESSOR,BTU ���`'�� ��j ROUGH � �
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2Z? �,, � � �.. -�:,--,i :
NOTICE TO A PLICANT: If, afler making this Cerlificate of VENTILATION SYSTEM hWAI �J' :' I.r�,�� ' .
Exemptian, you should become subject to the Workers' --
Compensotion provisions of the Lobor Code,you must forth- EVA70RAiIVE COOLER VI411�qTION�
with mmply with such provisions or this permii shall be — .
deemed�evoked. � FURNACE: rAU viiv �����
LICENSE�CONiRACTORS DECLARAiION FIOOR g7�� � L' �
I hereby affirm that I am licensed under provisions of Chapter 9 HF.ATER�. SUSPFNDED UNIT_
(rommencing with Section 700D)of Division 3 of+he Business � '/�A�i
and Professions Codc,ond my license is in full force ond effect. }
A 0.
License Number���Li�.Cl�ss����Q o
,� _> � ► FJ
Contractor QS����y"-.a Date ��� �
❑ — �
I om exempt under Sec. V
cta
I P an c eck fee I �
8.8P.C.for ihis reasan
p��p PERMIT ISSUING FEE$ �.) ?
Signo�ure TOTAL PEE
OWNER BVILDF.R DECLARATION PIAN CH(IX APPLICANT
I here6y aihrm thaf I�m exempt from�he Conirattor's License ,
Law for ihe following reason(Section 7031.5, Rusiness and NAME
Professions Code),
❑ !, as owner oi the oroperfy, ar rny emplayees svith ADUNE55
wages as their sole mmpensation,will do Ihe work ond
the struc!ure is not intended or offered for sale(Sec�ion ��TY TFL.NO ,. '; �f.;,. �
7044,Business and Professions Codej. �
OWNER � �'^L�„� � �� y n c m a a�;
❑ I,as owner of the propeny,am exdusively mntracting v�
with licensed coNractors to ronstrurt ihe project(Seo- MnIL n c
tion 7044,Business ond Professwns Code). AD�RE55 �-�, j a n.`��� ``;C;
CONSTRUCTION LENDING AGENCY CITY � `�� TEL.NO.�� '� ^ �q ��.�� 1,;rr i
I hereby affirm Ihat there is a construciion Iending agency for � � �
ihe performance of the work for which this permit is issued CONTRACTOR
(Sec.3D97,Civ.C.). �� S� �?C�m`C''b
ADDRE'� �� /��
Lender's Nome L
CIIY r � TEL.NO. •'�' �) '
Lender's Address ! C
STATf. LIC
I certify that I have read this applicatiun and st�ie that the LiCENSE NU �� CLASS '"�
above Informotion Is wrred.I agree to mmply wilh oll Counly
ordinances and State laws relatinc�to building construction,
a here thorize rep sentotives of his County to enier
u o t e bo e-mentio properry for �spe fion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
n I, �. '
Sign rt�rc of Applicpnt�r A�ent Datc
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