HomeMy WebLinkAbout0996A (5) WORKERS'COMPENSA710NDECLARATION qpp��CATION FOR PERMIT �
I hereTiy effirm�that I have o terti(icale of consenl to self '
�nsure,or a certificaie oi Workers'Compensat�on Insuronce, ,bA3e�c HEATING - VENTILATING - AIR CONDITIONING
or a cerlifi�e�d�to,,p,py�fh�er�eyof(Sec.3800,Lab.C.) CE-BIB(REV,-10/81)
P❑olicy No.1QI��=Compony $T�►rE �Uab '
Cerrfied copy�s hereby f�rnished. COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
� Certified copy is filed wi�h�he co�nry b�ilding inspec- FOR APPLICANT TO FILL IN � BUILD�NG
iton deparfinent. ADDRESS 2[�$"I s �.J A�(rNV7
(PRINT OR TYPE ONLY)
oare J��7—� APPliconl���t�j iocnun W hLkJ lU'T
NO.� TYGE OF AP%.IANCE OR EQUIPMENT FFE
� CERTIFICATE OF EXEMPTION FROM WORKERS' - � NEaREST
COMPENSATION INSURANCE . � CR05557. �
(This sec}lon naod not br complsl�d if}ha work involved 6y RBSORPTION UNIT,BTU oisia�cr No. va SSED BY ,I
Ihs permtt I�!ar ona hundrad dollars(f100)er last.) � 6
I cerlify ihaf in fhe per{ormante of Ihe work for which this AIR HAN�LING UNIT,CFM �
permil is issued,I sholl not employ any person in ony monner BOIIER,BTU
so as to become subject 10�he Workers'COrt1Pen5a�iOf1 LaWS. A7PROVALS � DATE INSPfCfOR'SSIGNATURE
Da�e ePP�j�o�� �, COMPRESSOR,BTU � !� ROVGH
NO710E TO APPIICANT: If, ofler moking this Certi�ico�e of VENTILATION SVSTEM ' FINAL 7 �
Exemption, you should become subject to Ihe Workers'
Compensafion provisionz of Ihe la6or Code,you muzl forth- EVAPpRATIVE COOLER VALIDATtON '
wi�h comply wiih sucM provisions or this permit shall be '
deemed revaked. FURNACE: FAU_GRAVITY
IICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm thal I am licensed under provisions of Chopter 9 SUSPENDEo 11NIT_
. . HEATER: WA��
�(commencinq wilh Setlion 7000)of Division 3 of the Business }
ond Professions Code,ond my license is in full force and effett. -p_ - r � , / �S a
license Number��p7� Iic.CIo55�r�'O ��-� -_ � ,� ► . � tOJ
ce�„a�ro,�Q T�C.• S6'7�• Dale �6 7-�3� �� �/�a1 / ?0 9 9,6 A o
❑ . #. . . . .g �
I am exempt under Set. w
Plan check fee a
8.8P.C.for this reoson� '�
PERMIT ISSUING FEE S Z
Date:
Signature - TOTAL FEE � ,.S I • •2�'J 5
OWNER-BUILDERDECLARATION PIANCHECKAFPtiCANT�
I hereby oftirm�hot I am exempt from the Conrractor's License � • � •2 u 7 Jr c=-+
Law tor ihe foliowing reason(Sec�ion 7031.5,Business and NAME �� � -- �f/GfjL S , t1l�fS5
Professions Code): �Q Q j_�']
A�DRE55 " S�'
❑ I, os owner oi�he properly, or my employees wilh (a��� G���30 �
wages as rheir sole compensation,witl do ihe work and
the structure is nol inlended or offered for sote(Settion CITV ����,�,� L.NO. C�/�/OL�
7044,Business and Professions Code). �
❑ I,as owner of the property,am ex[lusively[ontracling OWNER w�L�,�T VJ. ���iL •
with�licensed coniradors to consfrvct ihe projett($eo ��� - -- - -
tion 7044,Business and Professions Code). ADDRE55
CONSTRUCTION LENDING AGENCY CiN � � 7Et.NO.-- �-- � -- ��-
I he�eby afiirm ihal Ihere is a canslruc�ion lending agency(or �
the performonce of�he work for which this permir i:issued CONCTRAROR�Q�h-- - /LS�:.J� � � ,
(Sec.3097,Civ.C.). . . _.. _ . . . _
ADORE55 � ..pS % BLfIO: - - " . � .. . . -- '
� Lender's Nome ^.. �
C�iv �K-/�MOUN 7 . ..iFl.NO.��tf�7�. . _. . _ . � . ._
lender's Address -
STATE LIC.
I certiFy�hat I have read Ihis applimtion and state thot the LI�ENSE NO. ��� fLASS �� �� .- -
obove information is torrect.I ogree lo camply wilh all Co�n�y '
ordinonces ond Sto�e laws relating to building construction, . �
and hereby aothorize representarives of this Counry lo enter . . � � � -
u n� e above-meNione properry far inspedion purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE
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