HomeMy WebLinkAbout1623A (224) iWORKERS'COMPENSATIONDEC��.RA?ION APPLICATION FOR PERMIT �
I hereby affirm that I hove a certificate of ronsent to self
insure,or a certifim�e of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING L3
or a certified copy thereaf($ec 3600,Lah.C.) 76A364C
CE-RI B�REV.10/Bl J
P❑olicy No. ComFany
Certified mpy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND$AFETY
Certified w is flled with ihe counr 6uildin ins ec- FOR APPLICANT TO FILL IN su�to�NG
rlon depa,�menr. v s a (pRiNT aR rrPE oN�ri nnoR[ss d��(r31 LJiE�'e�� !��n� 1..�-�'
Date Applkao� �oca,urv��A;��oo�il �f1s2 3?fr:. c2+.=.��2Y
NO. TYPF OF APPLIANCE OR EGIUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSA710N INSURANCE CROSS SL �.�ftJZ. �iU�.
(This section need not 6e completed if the work involved by /+BSORPTION UNIT,BTU uiS�uiCi rv� raocrssFo ar
1�Ie permii is for one hundred dollars(5100)or less.) qIR HANDLING UNIT,CFM } �\ � \'�
I certify thnt in the performance of 1he work for whi<h this f i � �(�}'`Cj
4 permif is issued,I shall nof employ any person in any manner �
so as to become subjec�to the Work s'Compensation Laws. BOIIER,6TU ncveovau onrE iNsrFclox�ssicNniuu[
� ,) 1'C'� .^� h
'�' Date �u��d �+pplicant�i �� COMPRESSOR,BTU "1�,�dU �r.C! \� ROUGH
� NOTICE TO APPLICANT: If, after making this Certificate of � vEN71�AlION SYSTEM ��� }�n.]S � FlNA� ;r �
!, Exemplion, you should become subjett to ihe Workers' �L
�i Compensation provisions of the Labor Code,you mus�forih- EVAPORA7NE CbO�ER LI ATION
�# with comply with such provisions or this permit shall be
deemed revoked. L"1 FURNACE FAU �AVI7Y �
LICENSED CONTRACTORS DECLARATION C.3i FLOOR BTU -
,� I hereby affirm that I am licensed under provisions o4 Chapter 9 HEATER- SUSPENUED UNIT—
'1 -(mmmencing wiih Section 7000)of Division 3 of the Business WALL
q� ond Professions Code,and my license is in full force and effect. r ' 1� �
Y s4 �' `K� �
� Licensc Number Lic Class � ^�� , �
� �
Contractor Date �
� ❑ �
I am exempt under Sec C� �
Plan check fee `'�, � N
,
8.8P.C,fo�this reason PERMIT ISSUING PEE$ '(� _a� � �j.L,� �
Date:
� TOTAL FEE C
� Signature
OWNER BUILDER DECLARATION PLAN CHECK AVPLICAN7
� I hereby affirm ihat I om exempl from rhe Coniractor's I icense ,
�� Law for the following reason(Section 703L5, Business and NAnnf
Professians Code):
❑ I, as owner of the property, or my employees with A�DRE55 �
wages as iheir sole compensation,will do the work and �.�TY 7EL NO
� the struUure is not iniended or offered for sale(Seciion
7044,Business and Professions Code). "� f.� {�
OWNER�(j� � '
� I,os owner of ihe properly,am exdusively conirocting .
with licensed contractors to�onstruct ihe project(Sec- � MAIL f�f'� ��t;���7�� , e r, c x;}
� lion 7044,Bus�inzss and Professions Code). ADDRE55 ( _ ; o '
CONSTRUCTION LENDING AGENCY aiy �1�..•zNnij �/a. re�.NO�� !G r"�/V ?�"�C C�
I hereby affirm ihat there is a consiruction lending ogency for P'�� r� ,
- the performance of the work for which this permit is issued - �ONTRACTOR. � �j�—�__,[$L� '0 ° i C^� �--�-�
j (Sec 3097.Civ.C.). —�
3 � F�DDRE55 '�J�1� � f'`�t`)
a Lender's Name —
� . CITY TEL NO-
Lender's Address
$TATE �IC.
I certify Ihat I have read this applicotion and slate ihat ihe - LICENSE NO. CLA55
� above informolion is cor�etL I agree to romply wilh all Couniy
ordinances and State laws reloting to building construdian,
and by authorize representatives of this County to enter
upon�h above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� �.-�.-�c,..�..� �f.�iS�-iIB.
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