HomeMy WebLinkAbout1329A (180) WORKERS'WMPENSATION DECLARATION qpp��CAT10N FO� PERMIT � I
I hereby affirm that I hove a certificate of consent to self �� �/
ins�re,or a certificate of Workers'Compensation Ins r ce, f�' �l
or a tertifie e�pp,� �en�ac HEATING - VENTIIATING - A!R CONDITIONING O
CE- 18(REV.10/BI)
Volicy No ny / '
Certified copy is hereby furnishe COUNTY OP LOS ANGELES BUILDING AND SAFETY
Certified topy is filed with the county building ins c- FOR APPLICANT TO FILL IN BUILD�NG /
ti ep e AD�RE55
(PRINT OR TYPE ONLY� •
Dafe � pPficaN LOG4LITV
NO. TYPE OF APPtIANC�OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F M WORKERS' n�.aReST
COMPENSATION INSURANGE CRO55 ST. r�
(Thls wctlon naad nof bo camplof�d N fb�work involr�d by ABSORPTIqN UNIT,BTII DISTRICT NO- P ESSED
tho pormif Is lor ono hundrad dollors(S100)or Iru.) q�R HANDLING UNiT,CFM �
1 certify that in the performance of the work for which this ��
permif is issuad,1 sholl nat employ any persan in any manner gOIIER,B1U
so as to become su6ied ta the Workers'Campensotion Laws. qppRovn�S DATE INSPECTOR'SSIGN/iVRE
Data 0pplicont COMPRESSOR,BTU ROUGH �
NOTICE TO APPLICANT� If, aNer moking lhis Cerfificole of VENTIlA110N SYSTEM FINAL ,
Exempfion, yau should 6acome subject to tha Workers'
Compensation provisions of the Labor Code,you must forth- EVAPORAiive COoieR VALIDATION E
wilh comply with such provisions or this permit shall ba -
deemed re�oked. FURNacF: Fnu r
LICENSED CONTRACTORS DECLARAT�ON FlOOu
I hereby affirm thol I om licensed under provisions of Chopter 9 HEATER: SUSPENDED UNIT_
(mmmencing with Section 7000)af Divisbn 3 0#iha Businass - Wa�
and Professions Code, y � e is in f force d ffe Y�
License Number ¢. la � — ^ V
f �
Contra t : ;� ;� O
� I om exempt under Sec. •-- �{,� _ W
Plon check fee � � - •- d
- B.BP.C.for this reason pERAAIT ISSUING FEE s . • T e , � . � � �
Date: � :'. ,� ; `.
Signature TOTAL FEE
OWNER-BUILDER OECLARATION PLAN CHEIX APPUCANT �
I hereby aHirm thaf 1 om esempt from Ihe Conlroctor"s License � ,
Law for the tollowing reason(Section 7031.5, Business and NAME
Professions Code): ' '
❑ I, a5 owner of ihe property, or my employees wilh AD�RESS �
wages as iheir sole compensa�ion,will da ihe work and
the struUure is not intended or offered for sale�Section C�TY TEL NO. �
7044,Business and Professions Code). /
OWNER �
❑ I,as owner of the property,am ezclusively contractinq
with licensed coNradors to consiruct the project(Ser �`'U`��
tion 7044,Business and Professions Codej. ADDRE55
CONSTRUCTION LEND�NG AGENCY � �
I hereby affirm that there is a conslroRion lending agancy for
�he performance of the work for which�his permit is issued CONTRACTOR
(Set.3097,Civ.C.).
ADDRE55
Lender's Nome
v � /_
lender'sAddress �" (fJ
I tertif that I have read this a lication and slate Ihat Ihe ST E uC.
y pp UCENSE NO. CLA55
ubove information is correct.I agree to comply with all County
ordinances and Staie laws relating to building ronstruction,
and hereby authorize represen�at��es of this County to enter '
upon the �ov -m, ion d ra, rty for inspecrior+pu� oses $EE REVERSE FOR EXPLANATORY LANGUAGE
� /�-�; �
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