HomeMy WebLinkAbout1317A (37) WORKERS'COMPENSATION DECLARATION �APPLICATiOR! FOR PERMIT �
I hereby affirm that I have a ter�ificate of tonsent to self
insure,or a cartifico�e of Workers'Co ensation In urance, �
or a cenifi r f(Sec.3800 � 76A364C � HEATING - VENTILAiING - AIR CONDITIONING �
/' CE-818(REV.10/81)
Polity N � o�ipany l.. i
Certified copy is here6y furnished. nf COUNTY OF LOSiANGELES BUILDING AND SAFETY
Certified copy is filed with the county building insp - FOR APPLICANT TO FILL IN BUILDING
fi n de rtm 1 (FRINT OR TYPE ONLY� A�DRE55
�ate Applicam lOcnuTv
O. TYPE OF APPIIANCE OR EQUIPMENT FEE
CERTIfICATE OF EXEMPTION F DM WORKERS' t�EAREST � �
COMPENSATION INSURANCE CRO55 ST.
(Thit sae�ion n�od no+b�complNed if Ihe work inrolved 6y ABSORPTION UNIT,8TU ' DISTRIR NO. P ESSED BY
�ho porml�b lor one hundrad dollars(5100)or I.aa.) �
1 certify ihat in ihe performance of ihe work for which this
AIR HANDLING UNI7,CFM
_ permit is issoed,I sholl not employ ony person in any manner gp��ER,BTU
so os to become suhject to the Workers'Compensafion Laws. nv�aovnts o�re 1NSPECTOR'S SIGNATURE
Date App�i�ont COMPRESSOR,BTU ROUGH '7�y /y�
NOTICE TO APPLICANT: If, ofter making this Cerfificate of VENTIWTION SVSTEM FINAI
Exemption, you should 6ecome su6jed to the Workeri
Compensolion proviaiore of the labor Eode,you must fwtb- EvnvORATtVE COOiER VALIDATION �
with comply with such provisions or this permi� shall be
deemed ravaked. FURruCe: Fnu G I
tICENSED CONTRACTORS DECLARATION FtOOR
I hereby aHirm that i am licensed under provisions of Chapter 9 SUSPENDE� UNIT_
kEATER WA
(commencing with$ection 7000}of Division 3 of the Business
and Professions Co nd ce n full force c �
License Number tic. �ass � y �
i �
Contra• te � �
❑ I am exempt under Sec. 1 � W
Plan check fee yd 1� �d d
B.&P.C.for this reoson 1 • •_.�, i . Z
Dare:T_ PERMIt ISSUING FEE S , , . j
Signature TOTAL FEE tl � � `
OWNER-BUI�DER�ECLARATION PLAN CHECK APOLICANT I (,��CJ—„.,
1 hereby affirm that I am exempl from the Contraclor's License �
Law for the following reason(Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the properiy, or my employees with AWRESS .
wages as iheir sole compensafion,will do Ihe work and �
ihe shucrore is nol intended or otfered for sale(Section CITY 7E�.NO. �
7044,Business ond Professions Code). �
OWN�R
❑ I,as owner of the property,am exdusively rontracting
with licensed conlradors ro ronsiruct ihe project(Sac- �'��
tion 7044,B�siness nnd Protessions Code). ADDRE55
CONSTRUCTION�ENDING AGENCY � �
I hereby affirm that Ihere is a cons�ruction lending ogency for
ihe performance of ihe work for which ihis permil is issued WNTRACTO
(Sec.3097,Civ.C.). �
ADDRE55 �
Lender's Nome
Lender's Address
C ' f �
I mrtif tha�I have read this a licdion and s�ote tha��he ST LiC.
y pp LICENSE NO. C1A55
above info�mation is correct I ogree�o comply with oll Coumy ,
ordinances and State lows relating fo building consfruction,
and hereby outhorize representa es of ihis County to enter
upon t ab ve-�d ro rry for inspyction pur s � SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signoture f Applimm or Agenl Da�e .
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