HomeMy WebLinkAbout1331A WORKERS'COMPENSATION DECLARATION �7/���� qPPLICATI4N FOR PERMIT � �
I hereby afferm thot I have o certificate of consent to self r�G
ins�re,or a certifica�e of Workers'Compenso�io Ins�rance, NEATING - VENTILATING - AIR CONDITIONING �
or a cenif' h r of Sec.38 Lab.C. 76A364C
� ce- ia�eev.toiai� �
Policy N �ompan �/` �QUNTY OP LOS ANGELES - BUILDING AND SAPET
� Certified copy is hereby fvrnishe . .
Certified copy is filed with the cauNy building inspe FOR APPUCANT TO FILL IN BUIIDING �
fion dep im AOORE55
(PRINT OR NPE ONLY)
Date � � pplicanl LOCAlI7Y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFfCATE OF EXEMPTION FR WORKERS' NEARESi
COMPENSATION INSURANCE CROSS 5T.
(TMa aMlon n�ed noi be compl�Nd if TM work Involwd br AB�RPTION UNIi,8TU asraict No vxo o r
tha parmif ia for onv hundrod dollars(5100)or loss.) �.
I certify thot in the performance of the work for which IhiS A�R HANDLING UNIT,CFM ,
pe�mit ie issued,I shall not employ any persan in ony manner �'''�'�^� II
so as to become subject to�he Workers'Compensation Laws. eO��ER,eiu AVPROVALS DATE insPecTOR•s sier+nTuxe
Oo16 eppiicant COMPRESSQR,BTU ROUGH
NOTICE TO APPIICANT: If, af�er making this Certificote of VENT�LATION SYSTEM FINAL
Exemption, you should become su6ject to the Workers' r
Compenwtion provisions of fhe Lobor Code,you must forfh- EVAPORATIVE COOLER VALIDATION `
wi�h comply with such prnvisions or �his perm�� shall be �
deemedrevoked. fURNACE: FAU G
LICENSFA CONTRACTORS DECLARATION FIOOR
I herBby affirm that I om licensed under provisions of Chapter 9 HEATER: �SPENDED UNIT— , "j ;-� � r. �
(commencing with Section 7000)of Division 3 of ihe 8usiness +; . . . . _
and Professions Cod a my li nse's i full forc and eff f. e � �'
/� I � °�.? '� p I
License Num6er-� .Cla s�� ► - . '�._ V
• � i_,T oG
Cantraci 't u �
❑ I om exempt under Sea P�pn[heCk fee � �.�'i—��k � �
B.&P.C.for this reason PERMIT ISSU4NG FEE; �
Dote:
�
5i9nature TOTAL FEE
OWNER•BUILDER DECLARATIDN Pl.4N CHECK APPLICANT
1 hereby affirm thot 1 am exempt from the Cororador's License . �
Law for the following reason(Section 7031.5, Business and nIAME
Professions Code): .
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compansation,will do the work and �
Ihe structure is not intended or offered for sole(Section CiTr TEt.NO. ` ,
7044,Business and Protessions Code).
OWNER
❑ I,as owner of fhe property,am exdusively mmracting
with litensed mntradors to construct the projeU(Seo- ���
lion 7044,Business and Professions Code). ADDRESS
CONSTRUCTION IENDING AGENCY � � p �
i hereby affirm that�he�e is a construdion lendin9 agency for
ihe performance of the work for which ihis permit is issued CONiRnC
(Sec.3097,Civ.C.).
ADDRES �
Lender's Name
Lender's Address � �C/
STAT LIC.
1 certify ihal i have read this opplication and s�ate fhaf the I�CENSE NO. CLn55 -
obove informafion is corred.I agree to camply with oll Counry
o�dinances and State laws relating to building constr�ction,
and hereby authorize repre ent tives of rhis County to enler
upon� above- n ne pr arty for insp dion pur os SEE REVERSE FOR EXPLANATORY LANGUAGE
Signptu of AppticoN or Agem � Do�e
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