HomeMy WebLinkAbout1332A (234) WORKER$'COMPENSATION DECLARATION App�iCAT10N FOR PERMiT �
I hereby affirm that� have a certificate of consent to self ��
insure,or a certificate of Workers'Com nsation Insur nte, V��
or a cer�ifi c � f( 3 , C. 76A36aC HfATING - VENi1lATING - AIR CONDITIONING � `
CE-818�REV.10/ei� �
Policy No d� � ,
Cer�ified copy is hereby furnishe . COUNTY OF LOS ANGEIES BUILDING AND SAFETY
Certified copy is filed with the co�nty buildin insp - FOR APPLICANT TO FILL IN eUILD�NG P
fi e m (PRINT OR TYPE ONLY) AD�RE55
Date � plitant LOCAIITY
O. NPE OF APPLIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FR WORKERS' Neqpe57
COMPENSATION WSURANCE CROSS ST. ��
(This seNion nNd nof b�complofod iF Iha work Inrolr.d by ABSORPTION UNIT,8TU �ISTRICi NO ra SSE�BY
tha pormit la tor on�hundrod dollars(5100)or ku.) ^
I certify that in the performance of the work for which this AIR HANDLING UNIT,CfM '�
dL �'t-�C�Yr�J�+f
permit is issued,I shall no�employ any person in any manner gp��R.BTU
so os�o become subject to the Workers'Compansotian Laws. nvvrzovnis OATf Ity5PEC10R'S SIGNATUGf
Date �pplicont ' COMP(tE550R,BtU ROUGH
NOTICE TO APPLICANT: ff, after making this Cer�ificate of vEMi�471oN SYSiEM FlNnI � �
Exemption, you shauld become.subject to ihe Workers' �
Compenwfion provisions of the Labor Code,yoV mVSf fONh- EVAPORATIV/E COOIER VAUOATION
wiih compiy with such provisions or this permif sholl be .
CJeemetJ fe�Oked. FURNACE: FAU G
LICENSED CONTRACTORS DECLARATION FlooR T
I hereby offirm that I am licensed under provisions of Chapter 9 Sl15PENDE� Unlii_
-(commencing wi�h Section 7000}of Division 3 of the Business HEAtER� WA�
and Professions C nd m fi ense' � full force d fect y
a
License Numbar ic.Clau ► V-
/
Contra �
a
❑ _ i ,"�%i' �v
I om exempi under Sec.
Plan check fee e c N
8.8P.C.for this reason r� ' " • • _
PERMIT ISSUING fEE S ?
Date: � • e ^ .
Signature TOTAL fEE � _ _
OWNER-BUIIDER DECLARATION PLAN GHECK AFPLICAN7
I hereby affirm ihat I am exempt from the Coniractor's License � j _?,_ , ,
Law for rhe following reason(Section 703L5, Business and NAME
Professions Code):
❑ I, os owner of Ihe property, or my employees with ADDRESS
wages os their sole compenso�ion,will do the work ond . �
the structure is not intended or offered for sale�SeUion ��TY rEl.nio. . �
7044,B�siness and Profassions Code�.
OWNER
❑ I,as owner of ihe property,am exclusively conlracting �
with licensed mntractors lo construct the project(Seo- ���
tion 7044,Business and Professions Code). ADDRE55
CONSTRU�TION LEND�NG AGENCY �i r �
1 hereby affirm that there is a construction_lending ogency for �
the performance of the work for which this permit is issued CONTRACTOR
(Sec.3097,Civ.C.). _
ADDRE55
lender's Name
/ /
Lender's Address uj
I terfit thal I have read Ihis o lication and stale ihat Ihe 1 TE IC.
y PP LICENSE NO. CLA$$
above information is correct.I agree ro comply with all County
ordinances and State laws relating to 6uilding consnuction,
and hereby oufhorize repres nloti es of this County to enter
upon the a ve meo' n I op y for inspecGo �rp��� SEE REVERSE FOR EXPIANATORY LANGUAGE
Signoture of A licont or Agent Dote
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