HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (56) WORKERS'COMPENSATIONDECLARATION � App��Cq��ON FOR PERMIT �
I here4y affirm thm I have a cerlificote of consent:o self
� insure,or a certificate of Workers'Compensotion Insurante, �6A364C HEATING - VENTILATING - AIR CONDITIONING "
or a certifie copy thereo (Sec 3800, b.Cy) CE-818(REV.10,'81;
P❑olicy No���ompany C�UNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby fumished. .
� Certified<opy is flled w�th rhe county building inspeo- FOR APPLICANT TO PILL IN �� � � � Bui�o�Nc�
tion epari eni. ADDRE55 ,J�
�' J / � (PRINT OR TVPE ONLYI �'\
�PBfe ppli<ant ��x-(�..i�1 dl S u�l�L`�� ' LOCFLITv \
`NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
RTIFIC TE OF EXEMPTION PROM WORKER$' NEAReST
WMPENSATION INSURANCE - CR0555T.
(This secfion need not be compleled if the work involved 6y /+g�RPTION UNIT,BTU oi5ia;c Ho. azocesseo gr
The permit is for one hundred dollars(j100)or less.) Aie HnNoIInG UnliT,CFM j /t y �rn �
I cenify that in ihe performonce of the work for which ihis ... ... �lj ��`�
permit is issued,I shall nof employ any person in dny manner
so as lo become s�bject to the Workers'Compensation Laws. BOILER,BTU qFPROVFlS CATE wsee a�s sicnar�ae
Doie Applicant COMPRESSOR,BTU ROUGH
NOTICE i0 APPLICANT: If, after making ihis Certifimte of VENTiLATION SYSTEM `iNA�
Exemption, you should become subject to the Workers' � ____
Compensation provisions of the Labor Code,you most forth- evnaORaiNE COOIER g � VALIDATIQN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU�GRAVIiY
LICENSED CONTRACTORS DECLARATION F�OOR eiu
I hereby affirm ihat I am licensed under provisions of Chapter 9 HEAiER: SUSPENDED 'JNIT_
(commencing with Secfion 7000)of Division 3 ot ihe Business - wA��
and Professions Code,and my license is in full force and effect. � � � }
� a
Li<ense Num6er����_Lic.Closs� ' , , C1
i.-�,, �7759A �
ContractonNW�'�_Date v
❑ I am exempt under Sec. �e „ a s�C �
Plan check fee a
B.BP.C.for fhis reason � j e o � �7,�, �
PERMI�ISSUING FEE S
Date: �. a '"
TOTAL FEE 'f3.�'O r i ' �""
Signofure „ �f
OWNER-BUIIDER DECLARATION PIAN CHECK aPPLi�ANT ��rt C - �'�R�]� �Q��I� C J,%; -H C
I hereby affirm ihat I om exempt from the CoMroctor's License ����� �-, ,
Law for ihe following reason (Section 7031.5, Business and NAME �
Professions Codel: � �
❑ I, as owner of the propery, or my employees with ADDRESS �� � �
woges as thelr sole compensation,will do the work and Ciiv� (�� �- TEL NO. 1�
ihe structure is not intended ar offered for sale(Seclion � ��.C.( �"g�QS�
7044,Business ond Professions Cadel. ' � �-�
OWNER �
❑ I,as owner of fhe properfy,am exclusively controding q'�� �Q � t
with licensed conlractors fo con5lruct the prajeci(Sec- qDDRE55 2 �� � ' p�i/ �}.�t-.� j�U a F
tion 7044,Business and Professions Code�. .
CONSTRUCTION LENDING AGENCY d7v rEL NO.. �j �a/;�.S
I hereby affirm that there is a constr�ction lending ogency for .
�he performance of rhe work for which rhis permif is issued CONTRAQOk �' � � �` � o�a �
l ) . t�s c. <.E'�y� 4�L ♦s rf� "` .n J �:
Sec.3097,Civ.C..
ADDRESS �� ��� G G:_�!�„�j 6
Lender's Name
CITY ' � . � a TEI.NO � J
Lende:s Address - . �
STATE �-�LI[. -
I certify that I have read this application ond state lhat the LICENSE NO. Q L✓� CLq55 �
above informotion is correct.I agree b comply with oll County --���• ���.- �..•,... ... . ..�-..__.. . , ,
ordinances and State laws relating ro building mnstructlon,
and hereby oufhorize�epresentotives of ihis County to enter
upon he bove-mentionecl�property for ins ection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�,. . � � �--_ ���,�1��
rSi o�A lican!ar A Aat ^�_
9no+��re PP 9en�
,��-...:,.�,��v.v. . :«..a.,...�.:�...�.,=a-e........,»`s^.,-.-..�-'-:-...�.,,.n...._.-_„-.-...,..-�....,.._f.,..,.
__ . -
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��� , _ _ �INSP�C7�Ct'S PIOT:� . OWNER-�U1LbER DECLARATIdN-
. . _ � he:eSy offirm ihoi I om exempt from�he Contraaor's
License La•.v sor ih� fallowinc reason (S=ction 7�31.5.
- ' � ' � Eusiness and professia.is CodeJ:.:ny c;ry ar munty which
. ---` � - � � requlres a permir ro consPruN,ol:er,improve,�de.molish,
�� ' ' or repair ar.y sSruc"ure, prior fo i4s Issucr,ce, a;so re-
_ , qvires the applicont for such permiP to?i!e a signed state�
- � �' - � ent tliot Fe is ficersed pursurnt to ihe pro. .,of tne
--- � CenProcto:'s ilcense!.aw iChepten 9;commcnrfng with
• ' � SecPion 7C60j of Division 3 06 tne 2usir.ess and Pro7�s-
—' — - sions Codej o�!ho%he is�xcmpt;he�efrom and:he basis
for 1he alleged examption. F.ny vfofo5ion of S�.t1on
� � � — 703L�by any.opplicant 3or a permit su6jects the appli-
. cont to a:ivi!penolty of not mora d'nen five hundred
� � , dollars(SSOO,i--
❑I,os o��v�.^.r cf ihe propary will dc•I-e work.crc!
�� rhe sirucNro Is net Inrended o o{fcred rer sol=_.
� - � ;'Sec.704d,9usirsess and Frofessions Cade: ihe Contrac-
. 'ror's License Low daes not apply to an owner cf property
- � � who hui{ds or improves iiiereor„ and�r�ho does such
— ---- -`-� vrork n,msc!{�rovided tAa/suc.h improvemaNs are ne;
- in;enoed or oifered for sale.1!,however.�fie cuilding cr
� . i rprovement is sold wifhir.oae y=_or o7 completion,thc
ov✓ne�-6uifder wilf nave the burden of proving ihoi hr did
. nof bulld or improve`cr 1he purpose of sale.J
_ _ ' � . ❑I,ds owner of fhc,propertY,am exdusiraly cor.-
trocting�,vi��!icensed contractor;tc c uct'he prol,er
ijec,7Ck+4;Bosines_and Profeseions Cod��7�ic Con9roc-
?nr's Licensc Law does naf appfy:`o�n owier of proper4y
_ w};o buiJds or i,mproves f!ereon,cr,d r�ha conir�:fs for
. � such projecfs uvith a contrvcior(s);iconsed pursuant lo
_ Ihe Contrac!or's Licsnse CawJ
� , I am exemp�under Sec _
8&P.C.for this raasan
Date
Oviner
INSPEG'SOR'S NOTEe , _ �