HomeMy WebLinkAbout1394A (11) WORKERS'COMPENSATION�ECIARATION APPLICATIOM FOR PERMIT �
I hereby affirm that I hava a certifica�e of consent ro self
insure,or a certificate of Workers'Compensation Insurance, ���� HEATING - VENTILATING - AIR CONDITIONING .
or a certified�copy thereoi(5ec.3800,Lab.C.)
iCE-818�REV.10/BI)
� P❑olicy No. Company
Certif�ed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wifh fhe counly building inspec- FOR APPLICAN7 YO Flll IN BUIL�ING r� p
, tion deportmenl. (PRINT OR TYPE ONIY) , ADDRE55 41� VNN�'� l�/t'
Dafe Applicant IOCAIITY �7���.yv�6/�(L ���
` NO. TYPE DF APCLIANCE OR EQUIPMENT FEE
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEARE57 � �� � ,
- COMPENSATION INSURANCE CRO55 ST. 'i
. (Thls weflon nNd noT 6a eomp{ofod if tho work involvad hy ABSORPTION UNIT,BTU oisreicr rvq. vrsocesseo ev 'ii
tho parmif is lor uew hundrod dollare(5100)or less.) �� '
� I cerfify that in the performonce of fhe work for which this A�R HANDLING UNIT,CFM
permit is issued,I shall not employ any person in any man�e� � `')� Q�Q � I
. so os ta become subjacr to the Wor ers'Compens ti n laws. BOitER,e7u a arvaovn�s oare iN FCTOWS SIGNATURE
'��/t+�/J . v COMPRESSOR;9iU ROUGH
' Dutei��p..p�PPlicanl .
NOTICE�TO ApPLICANT: If, of r aking this Ce itimte VENTILATION SYSTEM F�NA� I"j N.� ��.�v
� Exempfion, you should bec subject to t e Workars' -�
Compenwtion provisions of r labor Code,you musf forth- EVAPORATIYE COOLER VALIDATION
. with comply with such provisions or this permit shall be .
deemed revOkEd. FURNACE: FAU�_GRAVITY
' LICENSED CONTRACTORS DECLARATION FLOOR eiu
I hereby affi�m thm I om licensed�nder provisions of Chapter 9 HEATER: SUSPENDED uNii_ �
' '(commencing with Section 7000)of Division 3 of the Business ` WA��
� and Rofessions Code,and my�icense is in fvll force and effect. �'
O.
0
� License Numbar - Lic.Class � U
OC
Contmctor Date 0
� �139,4A ~
t am esempt under Sec. �
Plan check fee �� �� � �� �
B.&P.C.for this reason
PERMIT ISSUING FEE$ �
� Date: /� � ++v Q,J�Q i
Si nature TOTAI FfE O �2? _ �
9 •• •5Q50�
- OWNER-BUIL�ER DECLARATION PIAN CHECK APPI�CANT �.�r
't I hereby affirm ihot t am e:empi from the CoMmcror's litense . � �����8(�
Law for the following reason�Sec�ion 7031.5, B�siness and NAME. �� . _ .
�� Professions�Code�: � � �� - � � - �
❑ I, as owner of Ihe property, or my employees with ADDRE55 —
wages as their sole compensation,wiltdb iha wotk ond ��TY .r�-� . 7EL-�m.. r.�..�� ..
the structure is not intended or offered fw sale(Section � �
7044,Business and Professions Code). OWNER �� �,f �� /
❑ �,as owner of the property,om exclusively contrading �v�`
with licensed conhactors to construtt the project�Sec- N'p'�� �� �L' f7O�
tion 7044,Business and Professions Code).�- � ADDRE55 � 1//�/Y
CONSTRUCTION LENDING AGENCY Giv ��y ��-y�.. iei.NO. 1��I�6�/
I herehy affirm that there is a construction lending agency far , �
the performance of the wark for which this permil is issued ' COMRACTOR� �f����� � ��� - � � '
(Sec.3097,Civ.C.). � .
ADDRE55 � ��/d�
Lendei s Name
C�TY � tEt.NO.
Lender's Address
STATE LIC.
I certify that I have read�his applimtion and state that the LICENSE NO. - CLA55
above information is co�rect.I agree to comply with all Couniy
ardinances and State laws re�ating to building construction, � �
and heraby authorize representptives of ihis Counly to enter � -
up n tha bove-men i�o ed property for insp ction purposes. SEE REVERSE FOR EXPLANA70RY LANGUAGE
� qnalore of Applica t or qenl . . Dote
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