HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (143) TNCSRK$RS�'COMPENSATION DECLARATION APPLICATION FOR PERMIT
7 hereby�affirm ihlt I have a cenifimte of consent to self }��
insuae,or'a'`fertifimte of Workers'Compensation i�5�.a��e, HEATING - VENTILATING - AIR CONDITIONING �� '" � �
or a certified copy thereof(Sec.3800,Lab.C.) 76A36aC
CE-876(REV.10�81 J
POol�icy No. Company
Cert'rfied copy is hereby t�rnished. COUNTY OF LOS ANGELES BUILDING AND SAfETY .
� Ce.t�f�ed mpy is filed with the counry building��speo- FOR APPLICANT TO FILL IN eu��owG .f s�.. �� f,�-
tion deparYmenL (PRINT OR TYPE ONLY) ADDRE55 rt�
Date Applicont LOCALITV
NO. TYPE OF APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 Si.
(This sec4ion need not be complafed iF fhe work involved by /+B50RPTION UNI7.BrU oisr2�.a No, =aocEsseo av
the permit is for ona hundred dollars(;100)or less.) f� �� �
, I certify thot in ihe performance of the work for hich this AIR HANDLING UNIT,CFM
permit is issoed,I shall not employ any person in n monner gOILER,BTU
so as to become w jed fo ihe Workers pe ion Laws. naaR��:�n�5 C.vrE iNsceC?oe'SSi�vqruee
/ COMPRESSOR.BTU ROUGH J—��� L�r�.�-�—
�late • pplico
NOTICE TO A LICANT: If, fter akin rhis errificate of vEN7iLqiiON5v5TEM FiNA� _/Ji s
Exemption, you should eco e su ct to the Workers'
Compensafian provisions f e r Code,you m�st forfh- EVAPORATNE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION F'-OOR BT�
I hereby affirm thot I am licensed under provisions of Chopter 9 HEAiER: SUSPENDE� UNii_
(commencing with Section 7000)of Division 3 of ihe Business � WA'�� .
and Professions Code,and.my license is in full force and effecL d
License Number Lic.Closs � ' z r 7�3 4 p' y
�{.'`c ip a a`Z'� �
Controctor Date �,b " 1 G 5� V
❑ I am exempt under Sec �
Plan check fee � ° � v i 2.5�? H
B.&P.C.for this reason
PERMIT ISSUING FEE S � ."� I C,O 6'�� �
Date: TOTAL FEE `,�� �jZ}
Signofure
OWNER-BUILDER DECLARATION PLAN CHECK APPLiCANT
I hereby affirm ihat I am exempl from the Controdor's License ' {4 /�� �
Law for ihe following reason (Section 7031.5, Business and NAME �` e s o � •�.
Grofessions Code):
� I, os owner of the property, or my employees wifh A�DRE55 � B o�N v�`'
wages as their sole compensation,will do ihe work and CiTv TEL NO.
ihe sirucWre is not intended or offered far sale(Sec�ion ��- �b.�'i.�.�v%
7044,Business and Professions Code}. - �� ]
❑ I,as owner of ihe property,am exclusively contracting OWNER����LO�� �f�.v ,i � '� �.,�(�
with licensed controctors ta consiruct the project(Sec- MAIL
tion 7044,Buslness and Professions Code). ADDRES �""
CONSTRUCTION LENDING AGENCY ar � ie�.NO. �..���§
I hereby affirm Ihat ihere is a construciion lending agency for �
the performance of the work for whi<h this permit is issued �ONTRACTOR.� � ,
(Sec 3097.Civ.C.).
���/ ADDRE55� � �
Lender's Name
,�p�,�_ / CITY � TEi..NO. ` _(�.� � ��
Lender's Address �(� O�e�
$TATE !�C.
I certify rhat I have read rhis applica±fon and state thal the uCENSE NO.� CLASS
above information is mrrect.I agree to comply with all County ����
ordinances and Stare lows relating to building construction, '�
and hereby outhorize�r presentatives of ihis County to enter
9 the a6ove en lon'd property for inapec-on purposes- SEE REVERSE FOR EXPLANATORY LAN6UAGE
A2��' �
natum c`A pli �t a•Aoenr � Dote
i '
�,�,.��� "—„er'°rs ..�-s�.r�r- . :,...V_„�...�,� . .. °�w:
i�dSPFCYGIR'S tdQFES ' O`d1(NEP.-�lJILDER DrCLAR:�TI'Ohl'
. I hereby a`firm ahaf I am exemp!from+he Contrcctor's
. � Gcense Law for the foi!owicc rsason !Secfion 703�.5.
5usirass ond Prolessions Codej:Ar,y ci;y a-ccunty which
_ � . � requires p permit 9c corut;oct,cltar.improve,dcmclisb.
� or repair any struc7ure, p�icr;o it= issuance, c!sa rc-
- '� , quires yfie applimnt fcr such permit 7o file o signed stafe-
- _ menP thot he is licensed pursuant tc the provisions cf tF,e
Centrpdor's License law(Chopfer 9(mmmancinc wifh
� Sect'ron 7000j of uivision 3 af tne 6usiness ord Profes-
� � sions CodaJ o--fhot ha�s exemp!!hcreirom ond iha bosis
� � £or 'h.e atl�ged e �r,p�ion. Any viciaPion of Sectior.
. . � , J031 S by any app!i.oni 4or c pervnit subjecPs tl;e cppli-
� canP to a<ivil p�no!ty o�not moro 7Lcn five hur,dred
— daflars(5500!.:
� C!,as owner of nc�c^operty will.do!he vrork,a^�d
_
� " rhe struc�ure Is rot in^ended�or offe;ed`or sale.
i Jec.7Qb4,2usiness and Pro?essicns Cede: 7he Centrac-
tar's License Lew does no1 aoply to an owner of properPy
who builds or improves 7hereon, and wSo does such
, worh hinseff p:�vided ti�at such rmprc�ements ore r.ot
�nfended or olfered for saie.Jf,however,the bui;c4ng or
,' �� irr;provement is;o(d wiJhin or,e year of complefion,the
o4vr.er-burfder wil!have fhe burden of prov7ng�ho!he did
- , na�build or improve for;he purpose af safe.) �
� _ ❑I,as owner o`the praperiy.am exclusively mn-
tracting wi�n licensod cortr�ctcrs�o consiruct!�e .
___ _ iSec.7044j 8usiness and Pro4sssions Cod�:The Confrvc-
. tor's Licensz Law dces not app;y�o an owne;01 proper,;
_ - _ v�ho 6uilds or improves fhereon,vnd v�ho mnfracts fcr
such project;wifh a contrartor(s)licensed pursuan�to
� � iha Contrec£or's License Law!. -
__ ______ I cm exemp'under Sec.
6&P.C.for ihis recson
-- Date
. . �•. � ' � � ' . . O�vner
iMSPECTOR'S MOYES - . �� . . ` . � ..-. ... . �
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