HomeMy WebLinkAbout7560AWORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance,
or a cern o 1 3800, C.
Policy N any
Certified copy is hereby furnished.
Certified copy is filed with the county building i sp -
tio dep rime
Date ppl icant
CERTIFICATE OF EXEMPTION OM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($700) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Cade, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
'(commencing with Section 7000) of Division 3 of the Business
and Professions Code, n my I' se is in ull force and effect.,
License Number class
Cont
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to canstruct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby outhorize representatives of this County to enter
up�taye �nd.operty for insp urposes.
'SIgnat e of Appllconi or Agent Dote
APPLICATION
FOR
PERMITI/zl;
PERMIT ISSUING FEE $
HEATING - VENTILATING - AIR
CONDITIONING
1
7eA3e4C
PLAN CHECK APPLICANT
NAME
,.
CE - 818 (REV, 16/Bl }
,�
CITY TEL, NO.
COUNTY OF LOS ANGELES�
BUILDING AND SAFETY .
FOR APPLICANT TO FILL IN
BUILDING
CONTRACTOR'""'"' Y -
ADDRESS
ADDRES
(PRINT OR TYPE ONLY)
LOCALITY
f i
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST,
ABSORPTION UNIT, BTU
DISTRICT No.
PROCE55EO BY
AIR HANDLING UNIT, CFM
w
BOILER, BTU
APPROVALS
1
DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
VENTILATION SYSTEM
FINAL
EVAPORATIVE COOLER
VALIDATION
::z
FURNACE: FAU
FLOOR U
HEATER: SUSPENDED 7_ UNIT
J
Plan check fee
PERMIT ISSUING FEE $
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL, NO.
OWNER
MAIL fry �•
ADDR S
CI ... O
CONTRACTOR'""'"' Y -
ADDRESS
STATE
LICENSE NO. ��$"i'.ag� C A55 I
Y
SEE REVERSE FOR EXPLANATORY LANGUAGE
I he eby affirm flhaT ! am: xcmp, from Phe'Con?rccfor's
€ icen_,o i_0v1! far ?ham foHcow€ng reason (vevriar?, 1(i37,5,
y;ri. - . -j per")Iii it uiier,it ,3rav:�, ciao rofisl
d 3"L -T s". on ?F sit'__.`.,. Fa, ,r Ior =0 !i5 .: Sl. r,' re afs,, -� e
Y, sA a,o;plic i ? i —.h.r..ar ri:` r . E rued
naaI ,, z:. 'ic:, rF=..ti p;E:c :'!7 < <G is E"oiiStt o. ;ic?
Lcq-,;r.JCior-'s € k. ertne UT"", {a`�,�aC,i�;Ji f 's {C'O:"tJi i"r� ?=?i?C? v""ih
Se-,Hci7 7000) :;' Di•;i:sWn ° Q fire lAsKms cad r=m:`es-
shna Code) or Got he 4 exempt AG',^i?Tmm and M(= bon
F'o- AnV V;Okoln o; 00i(^.fl
?;x, L5 by uny nWfic; N Or V perWt suWWA Me 0raF JJ-
,:ej ;' fu c crsiJ Fac-no-Ifyr of W9 More f;?or NM lwndwd,
down PNW:
C I, cis j�vri i of tic, v,,ill do ±hr. %,god-, ono'
the sir, edure Is F�o? 1,W� 'F)c':8c_I of off4F�r d for sale _
(Sc,c, 7vIV, r, c!E?ass +end Pi r..a:,00ns Code he Con ac-
Qe's Li::en Luvv
'il`?E`recrz, o. -,d vvho -a Czes SuF:h
wort, himsoli proWdud rigo smh inv%mwmmN am not
ir,rendod or ofor d bar so,,&. IT, ,. . ei, r`r'?2-uiJr..'iv;r or
WotrerMMI 7 soir'` ._<✓ir?ir7 c,n;:* .'^ar�OF Corllp!eriOTr , �ir`,e
vwr?er-ibu;uor 1"PH i vc: : hi -aur rn of P.;rn:=ir:_= ?ria; 110 dig'
n excfusiveEy con-
onsrrucr
7 0�^�,2�ro'r,r,mperfy
ho Wks or ltYlyov.^-.s Owe= and 'Wrier co- kods for
°f,i6 bY'r:,Pww ';'..N aCr4+ri'i'rf; '!'�','{ � J7 _..45 BG �r7 r!"a ;larrt to
1i 1-oofi ocN;5r`s L i^ean;o L,-, v,)
I am exec; W under Sec,
B F1 C- for Oil reason_
DM e
O v:`ner
WSPECT ` NOTES