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Home My WebLink About1418A (219) WORKERS'COMPENSATION DECLARATION AppLICATION �FOR PERMIT �� I hereby affirm Ihot I have a certificote o(mnsent lo self , � insure,or a cerlificme of Workeri Compensation Insuronce, 76A3baC HEAi1NG - VENTiLATING - AtR CONDtTiONING. o�a ce��ified copy ihereof(Sec.3800,Lab.�.) � ce-e�e(Rev.ioiei� s" , � P❑olicy No. Company COUNTY�F LOS ANGELES BWLDING AND SAFETY Certified copy is hereby furnished. Q Certifled copy is filed with the munty bu�iding inspeo- FOR APPLICANT TO FILL IN BUILDING lion depanmenf. � (PRINT OR TYPE ONLY) � , ADDRESS •'� �� . Date ��'!. Applicont � � IOCALITY � . . NO. TYPE OF APPLIANCE OR EQUIPMENT . FEE � . CERTIFICATE OF EXEMPTION FROM WORKERS' NeaREST COMPENSATION INSURANCE CR055 ST. - (This seciton naed nol b.comploled i(Ihv werk Involr¢d by ABSORPTION UNIT,BTU DISlRICI NO. PROCESSED BY i Ihe parmft h For ona hundred dollan(f100)or lass.) qiR HANDLING UNIT,CFM � . - . I certify ihaf in fhe performance of Ihe work for which Ihis 1 �� , I permif is issued,I sholl not emptoy any person in any monner �--'� � ----� so as to become subject to Ihe Workers'Compensafion Laws. BORER,BTU AGPROVAlS pA1S INSFEQOR'S SIGNAIURE Oate Appficant r, COM7RESSOR,BTU ttOUGH . NOTICE f0 APPLICANT: If, afier making this Certifimte oi VENTILAtION SvSTEM FINAL Ezemption, you should 6ecome subject Io iha Workeri Compensation provisions of the Labor Code,yo�must 4orth- EVAPpRATIVE COOLFR VALIDATI01� � with comply with such provisions or this permil sholl be , deemed�evoked. FURNAGE: FAU_GRAVITV LICENSED CONTRACTORS DECLARATION FLOOR BTU � ,„. . I hereby affirm ihat I am licensed ander provisions of Chopler 9 SUSPENDEO UNIT_ � S'�,�,�,(�•.N, } �(commencing with Section 7000)of Division 3 of fhe Business • HEATER: WA�� . , i(.!+:��.e'r} 6 and Professions Code,and my license is in iull force and effect. . p • •. . � V , . r;•:�,',��,:�': W License Number lit.Closs � •- � . J Contracfor Oole . .i��C��;'i'��" u. , ♦:'1 :�:N��"�wl�i:. OC ❑ I am e�empt under Sec. plan tltetk fCe � - . � B.BP.C.for ihis reason . . Do�e: PERMIT ISSUING FEE S ! ' "� � TOTAL FEE W $ignature y � - OWNER-BUIIDER DECLARATION ttAN CHECK AvaLICANT . 1 hereby affirm�ho�I am exempt from Ihe Confraclor's license �. law for the following reoson�Section 7031.5,Business and NAME � Professions Code): . , ❑ I, as owner of the property, or my employees with ADDRESS � . woges as Iheir sole compensalion,will do the work ond the strutt�re is not inrended or ofFered for sole(Secrion CITY TE[.NO. 7044,Business and Professions Code). OWNFR • ❑ I,as owner of ihe prope��y,am e.dusively contmcting . wiih licensed comractors ro mnstruct the projec�(Seo- �''U'�� tian 704a,Business and Professions Cvde}. /+DDRESS CONSIRUCTION IENDING AGENCY Ctiv 7FL.NO. , � I he�eby affirm thet there is a conslrudion lending ogency for � � _ tha performance of the work for which this permit is issued CONTRnC70R�,, (Sec.3097,Civ.C.). � AD�RESS . � - lender's Name CITV - 'TEI.NO. . lender's Address I certif ihol I hava reod Ihis a lication.and stale thaf the SiATE � liC. - . , y pp UCENSE NO. CLA55 obove iniormation is cartetf.I agree 10 comply with all Counfy ordinonces and$late laws reloting to 6uilding conslrutlion, . and hereby authorize represen�atives of ihis County�o emer -�` � upon iha obove-meniioned properfy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i Signa�ure of Applicon�or AgeM Oo�e.� I � . . , �.i ... � .... � � - l.r. � � , ��. ' " I_� i��.�_�_�.�.i.r�.i...,i . ` . ' i ' . .I ` � . I I i � i I � � � . 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