HomeMy WebLinkAbout1155 DIAMOND BAT BLVD MPENSA710N DECLARATION APPLICATION FOR �PERMIT - _ �
I f have a certifico�e of consenf to self
insi._,�� e of Workers'�ompeosatio�Insuronce, 76A36aC HEATING - VENTILAYING - AIR CONDITIONING
or a certifiea<opy thereof(Sec.3800,Lab.C.) CE-818(RFV.70/8i 1
P�ol�cy No. Campany COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
. . .. .,. . . ......... .�..;...., �o....,.. r:: -:.... . .
� Certifled copy is filed with ihe cou�ty building inspec- FOR APPLICA�IT TO FILL IN Bu���iNG
lion departmenf. ADDRE55���` � � (/
(PRIN7 OR?YPE ONLY)
Date Applicant . � LOCALITY �
, NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NenREST
COMPENSATION INSURANCE �R0555i. —�C�NQ �//�
(This secfion need not be compleled if}he work involved by ABSORP710N UNIT,BTU c�s?aicr ve � caocesseo er
the permif ia For one h�ndred dollors(SI00)or less.) la
I ceriify ihat in the performance of the work for which�his A�R HANOLING UNI7,CFM.
permit is issued,I shall nof employ ony pe�san in any monner
so as fo bemme su6jecl fo the Workers'Compensation Laws. BOILER.Bill q=reovn�s onre ,nsvec�ozs scNn*uae
l
�ate Appliconi ' ��;7 COMPRESSOR,BTU ROUGH
� NO71C TO APPLICANT: If, afYe making this Certificate of VFP�j,I�ATION M � , RNaL
Exemption, you should become subje<t to the Workers' -
Compensa�ion provisions of the Labor Code,you must forih- EVA70RATiVE COOLER VALIDATION �
with comply with such provisions or this permi! shall be
deemed revaked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION Fi00R aiU
I hereby aftirm ihat I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
HEATER� yyALL
� -(commencing wirh Section 7000)of Divisian 3 of the Business � �
ond Professions Cade,and my license is in full force and effect. • �q�,�s �O C✓� a
G�
License Number ��-� �S�(.. Lic.Class_�.__ � �//.p � � �
��/ � ('/i�/L-Cs.[�� �
Canirocior -���7�Date_��,[.�_ �
❑ I om exempt under Sec. su
Plan check fee :_4 9 3.1 R, �
8.8P.0 for this reason PERMIT ISSUING FEE$ �U � #; c c o s e�s �
Dofe:
Sg�at�re TOTAL FEE �v r �:�%a,J�
OWNER-BUILDER DECLARATION a!aN cHecK naaucnNr
I here6y affirm thal I am exempt from the Cantrador's License , $ '� °'l'�`'C t�j
Law for ihe following reason(Section 7031.5, Business and NAME �,� ����7
rofessions Code}:
IW as owner of the AODRE55
properry, or my employees with (f�
oges as their sole compensarion,will do the work and g
the structure is not intended or offered for sale(Sectian C!7Y' ��-� TEL.NO.�
7044,Bosiness ond Professions Code1.
OWNER �. s i
❑ I,as owner of fhe properry,am exdusively conbacting
wlrh licensed mntractors to construd the proiect(Sec- h�`��
tion 7044,Business ond Professions Code}. ADDRE55
CONSTRl1CTIONLENbINGAGENCV CITV U,. _ TE NO. f.� l6
I hereby affirm�hat there is a construction lending agency for
rhe performonce of�he work for which this permi�is iss�ed cOnITRACiOR �,� ,
(Sec.3097,Civ.C.).
ADDRESS .`,..�`�
Lendeis Nome
CITV �, TEL.NQ. 77.._f �
Lender's Address J-X�
STATE LIC. �
I certify ihot I hove read this oppliwtion and s�ate ihai the �ICENSE NO. � C'�_ASS
above informotion is correct I ogree�o comply with oll County .
o.dinonces and State laws relating to building construdion.
ond hereby authorize representatives of this County to enrer
upon�he above-,me.niion�e pro{terry for inspec�ion purposes. SEE REVERSE FOR EXPLMNATORY LANGUAGE
�`��'.��'���� �rs��2
Sig�a'ure o£Aoplicanr or Age�t ' �aie
. . ... . . .,�, , . .. . ......i�.;,� .
--lNSPECT@R'�AI�Y&.�a -'^— CWiJEE?-�sUlI.DE�E Jt..�e.r.,. ,.C)fv
. I hereby affirm tnpt! .mp'from ihe Conirocto%s
� - � ' — Llcensu iotv 'or ti�a icllo�N r.g rzason ;Secfion 7031.5
� B�sirtass cne Fro`essior�s Codel:Any city or woniy w;ich
� �' ' ��� requires a p�rmi4 to conssrur.f,olter,i;norcve,namolish.
� _ _ or reoair any sirucPufe, nrio.'7o its rssuance, a!so ra�
� _ � � � quires fhe appficcn:for suo5 permit to file a sigred stc'e-
. �nen9 thas he is li:ensed pursuunt fo ihe provkrcns o;ifie
Con;racPurs Lirensr Lmv;�,iap'rer 4;corrmencing wi'rn
� ' � - � Sec!ion 70pQ)of Civie:on 3 `/hE�6uvness and Pr-ofes-
� � � � sicr+s Gooej w 7hon c�is exempP lherefrom crd th=basis
� sor ihe ol;eged e oiion. hny violo?ion of Section
- - � 70Si.>yy cny apr!iccnt for a permH subjecls ihe a�pli-
nt to a ivil,oenol',y of not rno a.ihan five hur,dred
� � daOQrs(5500!.,
. L.i�,c er o+tnc property�vill do riie work... o
— - . tF siructur_"s, n:e���ded o offerec for sale. �
(Sec.YG44,3:.�sincss cndProiessiof;s G cre: 7ne Contra:-
� ' - . �tcr's Licc-nse Lcw doas rot apply 10 an owneC oi property
who buil.:s or improves t;eraon, qnd w6n doas sveh
. '� � �� ---- , H�ck hims.si¢�rc ided tha�such improvements a�o not
!nterded cr cff=red 4or sale !3,hewaver,Pn=bvilding o��
� irnprovc;.�er,:is snld wifn%n one y3ar oi compietion,the
� ewner-buildprwill have the burden of proving fhat he d�d
� noi buiid or improve�or the purpcse of scfe.l
� ___,_ ❑I,as owner of ihe proper:y,a xclusively con��
-. �-.— rerr�iag vri?h licenszd con'ractor=b cc.,-��r�.id`he pro�,ec•
_ . ___ i5=_c.7G-4)Qusiness,and Profession,Ccde. 7he Conirao
� --==1or';Lirense taw does not epply to on oviner o!proper7y
� v;no builds cr imprcvas thereon,cnd who cor.iracfs for
- '�� �"' ' ' such proja.is wri4h o ronlracPor(s)(icensed pursuon}to
� _ tbe Contracror',Cicense LaWj. �
� . ... . . .__.__�_. _ _ . _ . ..
__ I am exempl undzr Sec._____________
� � . - 6&F.C.for inis reason—__________
Dci�� -- --
— . . �. � - . .. .. ... ......... .. .
. - . Ow•ner--- � .. _--
� . - . . . ., ... �:...,�: _ .
iNS�@CTOR'S NOTES ,
,.. .. .. _..:��. .., -----. . ----- ..__ : .