HomeMy WebLinkAbout0050A WORKERS'COMPENSATION DECLARATION APP�,'CATIUN FOR PERMIT �
I hereby affrcm that I huve a terfi(icate of consent fo self , i/�j
insure,or a ce�tificote oI wo�kers'Compensofion Insuronce, ���4C HEATING - VENTILATING - AIR CONDITIONING 7
or a cerlifi d copy thereof(Sec.38 ,la . .) CE-818(REV.10�81� �
acy Np�Company - �r\X tOUNTY OP LOS ANGEIES BUILDING AND SAFETY
Cer�i/ied copy is hereby fumtshe . �J��j
Certified copy is filed with Ihe county building inspec- FOR APPLICAN7 TO FILL IN� OURDMG
tion deparlmenl. A�DRESS
(PI21N1 OR TYPE ONIY)
Dme�Appliconf � LOcnuiv (71 � .C� �
NO. TYPE OF APPIiANCE OR EOUI7MENT . FEE ��`
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARES7 ( ��J_
COMPENSA710N INSURANCE � qBSORPTION UNI7,B7U CR055 ST. �����
{Thf�sreNon nwd nof b�eompl•f�d�f fh�work involvvd 6y oisreicr ruo. vxocesseo er
fhv pvrmlf Is for on�h�ndnd dollors(5100)or Io�s.J q1R HANDLING UN1T,CFM !�
I cenify rhat in ihe performance o1 the work for whicb�his
permif is issved,1 sholl not employ any person in ony manne� gOItER,B7U
so as ta become subjea to the Workers'Compensalion Lows. ,( arvzovnis onre WSVECiOR'S S�GNATURE
Da7e Appli[pn1 ' COMPRESSOR,8TU ���`�� GU ROUGH .�Z�1
NQ�CE TO APPLICANT: If, oher making this Certificate of VENTIIATION SYSTEM FINAI 3y�L/
{ vrion, you should 6ecome subjeU to the Workers'
C rensation provisions of 1he Labor Code,you must forlh- EVAPORATIVE COOLER VALIDATION �
with comply wi�h such p�ovisions or this permit shal� be
deemedravoked. � FURNACE: FAU_G VIT n�
� LICENSED CONTRACTORS�ECLARAiION � � FtOOR eiu V �
I hereby affirm thaf I am licensed under provisions o/Chapter 9 SUSPEN�ED UNI7_
'(commencing wi�h Secfion 7000)of Division 3 of ihe Business HEATER: WA��
and ProFessions Code,ond my license is in tull force and elfecL � � >'
�Q]��f� a
License Number�.�Lj,..`f_Lit.Class �`� � � � t�1
✓
Contractor pote �� � . � �
� �oos.oA �
I am ezempf under Sec. w
Plon check fee �'b+ • •�8 a
8.8P.C.for lhis reoson� � "�
PERMIT ISSUING fEE S I r +4 9.7 5 �
Dare:
Signa�ure TOTAI FEE �� d(�9,7 5�
OWNER-BUIIDER DEC�ARATION VLAN GHECK APFLICANT � �7 2 h�8 6
I hereby alfirm thot I am exempt irom�he Controcfor's License. � � ,
law for the following reasan(Section 7031.5,Businets ond NAME
Professions Code): . � �
���, os owner o1 fhe properly, or my employees with ADDRE55 �
.� wages os their sole compensalion,will do ihe work and �I7Y TEL.NO.
fhe strouure is noi iniended or offered for sole(Sec�ion
704d,Business and Professions Code). � � � ,r t � _
OwNER l
❑ I,ps owner of Ihe praperly,�am eRcluiively contmcting MAIt �
with Ifcensed coMrocrors ro consrrud�he plojecf(SeC- qDDRE55
tion 7044.Business ond Professions Code). . �
[ONSTRUCTION LENDING AGENCY � �� CiTv Q' �--TEt.NO. - �
I hereby oHirm tho��here is o construc�ion lending agency for y.� ,
the performance of the work for which Ihis permif is issued CONTRACTO� l
(Sec.3097.Civ.C.). . .
AO�RESS �.-�— . . _ . . ' .
Lender's Nome �
, . CITV . TEL NO. �SL,f� . . . .. .
Lender's Address .
I certif �h 1 have read this a licalion and stale tha�Ihe SiATE LIC.
y pp LICENSE NO. CLASS� C D. . . ..
abo inf m fion is correcl.1 agree to comply with all Couny . , �
� ordi nt opppd State lows relating to 6uilding construtlion, � �
ond c �W orize representa�ives of rhis Cou �y�o enfer - � - � � . . � �-�� "' .
upo e ob v - en�ioned property for inspecti n purpases. � SEE REVERSE FOR E%PLANATORY LANGUAGE
��
Signature of APPlicanl or Agent �vle .. -. .. . . . . . . .
, ` z ' � INSrEC70R'S NO7E5 � OWNEf.-GUILDER DEGLARATION
` _.
-,_._ ,,, ,,, „� ., , „ _. ,.., , ,._ .' � -- I hereby aff�irm.thot I em ezemp��from the Conho'c�or's
"-' � "''�-`� �� ��� _ � License Low for the following reeson (Sadion 703L5,
. . . ._...-..__.._._.. .. .r_,....,T. . _... _..... . .. ... . . _._ . . . . ._._ .. ..' - 6uzMessondFrofessionsCode7:Anycilyorcounfywhich
� ; i �. - ,. . � � � ' 'requtres a�permit to constrv:t,olier,improve,demolish,
---- -� --�� � � � � -'� .-. - � � � -�� or repair any slroc�ure. prior to its issuonco.�also re-
� � � � � . � _ qulres ihe pppfitanf for such permil fo(ife;o siyned sfa}e�
� --� ---�- � -- . � "- - --�- � � � � � �- � � - menf thal he/z lfcensed pursuonf fo fhe provlsions o!Ihe
� -- � � Confrocfor's Licen'se lavi(Chop�or 9�(commoncl�g wifh
��� " '�-" "-"�,� � � "`�� �� �' �� � "' �� � - � Section 7000)of.Division 3 of fhe 6usiness and Froles-
' ' � � sions Codcj or iha�he is exemp�f6erofrom and fhe basis
. � . � �'� � • - �� . � � � !or Ihe ofleged e mpfion. Any viofo�ion o(Section
, xe
_ _ \ : _ _ , � , „�,703I.5 by aay opplicon7 for a perm�r subjeds fhe oppl�-
. , ,. � . _ . . � � ,coN to o clvll prnoliy of not more than(ivo hundred
... _.._. _._. __,._. . . . . . . . . dolfars(SSODJ.:
'� � . � .. ' . � ' ' � � ❑I,as owner of the property will do 5he work,and
. � ��--" `� - ' ' " - �� � - . . -�thc struGure i; o!intended or offered for sole.- � �
�,. ` .. . . ^ . -
.-.. ..-�.- '.:=:,.- __ .'. � . . . .. .. . . . � " " � �(Sec.7044,Business ar,d Proiessions Code:� The^^��troc-
�� � . � . � � ,,,�4or's Lt[ense Cew does no�cpply to an owner of ,cr�y
�---'--� �" � � wRo bullds cr improves.lhcreon. and wfio does sucfi
� . . . � . work h/mself pravided thor such improvem^n�s are not
.� - ' � � infendod or oitered for sole.II,howevor,ihe 6ullding or
. � � . ._. � � .. improvemenr is sold with�n cne yeor ot complo�ion.�thc
� - - � � -�- � wner6uifderwil!havo Ihc 6urdon of proving fhaf ho did
' , , � � � ���nof 6uild or Improve 1or fhe purpose of sala) � �
� ' - �1,os owner of Ihe property,am exclusive(y con-
. . . � -- �- trocling with lice^sed ceMranors ro c rucl�hc projec�
. . (Sec.70ad)6usiness a�d Pro�essiore Code:The Controo
. —�� � tor i License Law does nof apply fo an owner�of properly .
� . � ' who buifds or ImproJes ihereon,end.who conlracfs lor
� • � �� � � such projecfs wilh a confrodor(sJ ficensed pursodnt lo
� � -- � -fbr Controclori ticensc Low). ���' ' � '
. � - ' I am exempt under Sec
� � � B 8 P.C.for thls reason ' �� �� �
. __... ._._ _ ...,. . . . .
. ; � � . Date ' " �
� . . . .� . . � ,_. _. � . � _ .. � Owner . . .. . . . �
INSPECTOR'S NOTES � - � - � � ������ � � �