HomeMy WebLinkAbout1316A (16) WORKERS'COMPENSATION DECLARATION ���%%���� t4PPLICATION FOR PERMIT �
� hereby affirm ihat 1 have a certificale of consen to If
insure,or a certificate of Workers'C pensa�ion i��� . 76a�ac HEATING - VENTILATING - AIR CONDITIONING�3
or a certif r c.3 la6 C.) �_818(REV.10/Bi) I
Policy N C pany � � I
Cerlified mpy is hereby furnishe . �� COUNTY OF l05 ANGELES BUILDING AND SAFETW� I
Certified copy is filed with the caunty building inspec- FOR APPLICAIVT TO FILL IN euuo�NG �
ti de �1r�r��,/��JJ,/� (PRWT OR TYPE ONLY) ADD2E5S
Date��2�--..'t-^PPIi[anl� NO. TYPE OF APPIIANCE OR EQUIPMEN7 FEE LOCALITY
CERTIFICATE OF E%EMVTION F OM WORKERS' NFAREST
COMPENSATION INSURANCE CROSS 57.
(Thi�faNfon n��d nof M complotod(f tha wotk inrdwd 6y ABSORPTION UNIT,BTU DISTRICT NO. VR sseo a
fha pormit i�for one hundred dollon(5700)or lou.) qIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this ��J
permit is iss�ed,I Sholl nof employ any pBrson in any manner
ao as to become s�6ject to the Workers'CompensoMion Laws. ��LER,BTU APPROVALS DATE INSPEC70R'S SIGNATURE
Da�e �pplicant CDMPRESSOR,8TU ROUGH �-��
NOTICE TO APPLICANT: If, after making this Certificate of VEtdnIATION SYSTEM FINAL
Exemption, you should 6emme subject to the Workers' �
Compenwtion provisions of fhe Lobor Code,yo�must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or ihis permit shall be . �
deemed revoked. FURNACE: FAU TY
LICENSED CONTRACTORS DECLARATION FLOOR e u
I hereby offirm fhat I am licensed under provtsions of Chap�er 4 SUSPENDED UNIT_
�(commencing with Section 7000)af Division 3 of fhe Business HEATER: wA
ond Profeuions Code my � nae i � full forca ec Y
d
License Number �c lass ,,i ,'j j �Ci. V
� �. . • e e oC
�apif f �a Q
I e �` i 4i r. u
� 1 ,. ..
1 am ex.empt onder Sec. �
Plan check fee
8.8P.C.for ihis reason • � . , �'= w
PERMIT ISSUING FEE S z
Date: - j :>�r_:: r.,
Signawre TOTAL FFE / �
OWNER-BUIIDER DECIARATION PIAN CFIECK APPLICANT
I hereby affirm that I am exempr from rhe Contractor's License �
Law for the fo�lowing reason(Secrio�7031.5, Bosiness and NAME ,
Professions Code):
❑ t, as owner af the property, or my emp�oyees with ADDRESS �
wages as their sole compensa�ion,will do the work and �
the structure is not intended or offered for sale(Sedion ��T� TEL.NO. �
7044,8asiness and Professions Code). - -
OWNER
❑ I,as owner of ihe property,am exci�sively con}rading
with licensed mntrocrors ro construcf the project(Sec- '�'A�� � �
tion 7044,Business and Professions Code). Ao�RE55
CONSTRUCiION LENDING AGENCY N� Q
I hereby affirm that there is a construction lending agency for �
ihe performance of the work for whith lhis permi�is issued CONTNACTOR �
(Set.3097,Civ.C.). .
ADDRE55 t
lendei s Name
� l�lender's Address �
I certif Ihat I have reod this a licaiion and state lhot the STA7E IC.
y pp LICENSE NO. CLASS
above information is correc�.I agree to comply with all County
ordinances and State laws rela�ing ta bvilding consiruction, .
and hereby auihorize repres ntgt ves of fhis County lo enter
upon th bove-me ri e r aert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
$ignaNre o Applicanl or Agen� Da�e �
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