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HomeMy WebLinkAbout0609 WORKERS'COMPENSATIONDECtARATION . APPLICATION FOR PERMIT � I he�eby offirm ihot I have a cerrificare of consent.to self insure,or o cerlifica�e of Workers'Compensotion Insurance, �bA�� - , HEATING - VfNTILATING - AIR iCONDITIONING � or o cerlified copy�hereof(Sec 3800,Lob.C.� � CE•818(REV.10/81) - � �Policy No._Z�Company s�����.a- [OUNTY OF LOS ANGELES -. BUILDING AND SAFETY �.. �� Cerlified copy is hereby(urnished. Certified copy is filed with the coumy building inspec-- F�R APPLICANT TO FILL IN BU4�iNG�, �/ fion depor�fin`e�nt (CRIM OR TVPE ONLY) ADDRE55 � Q� - Da�e�_�7 � ApplicaM LOCALITY NO. TYPE OF APPLIANCE OR EOUIVMENi FEE CERTIFICATE OF EREMPTION FROM WORKERS' nleAkESi i COMPENSATION INSURANCE Ca0555T.I � (Thla��ctlon nwd nol ba complaled if the work Involvad by ABSORPTION UNIT,BTU DiSiRiCT NO. VROCESSEO BY tl�a parmit is for ono hundr�d dollan(S100)or less.) qIR HANDIING UNIT,CFM '� �/� (�/� I cerrify thaf in the performonce of the work for which this ' �J \\ \ p�_ permit is iss�ed,I shall not employ any parson in any manner BOILER,BTu so os fo betome subjeU lo the Workers'Compensafion Lows._ avvrtovA�s Part iNsv[ci0a5 GNAiURE �a1e Opplicpnf � COMPRESSOR.BTU ROUGH � O^�� NOTICE TO APPIICANT: If, �aiter making ihis Certificale of VEN7IIATIONSYS7EM FINAL � Exemplion, you shauld betome su6jecl fo the Workers' Compensafian provisions of�he Lobor Code,you mu5f forfh- EVAPORATIVE COOLER �/f��ID/�TIDN wiih comply with soch provisions or �his permii shall be ', deemed revoked. FURNFG3:�� FnU BTU GRA�11`Y� . OQ � IICENSED CONTRACTORS�ECLARATION � ROOAd��tst.,u[i[,L K�� � I hereby af(irm fhat I am licensed under pro�isions of Chapter 9 SUSPENDED UNIT_ I, � HEATER: Wp�� � '(rommencing wi�h Section 7000)of Division 3 af fhe Business } and Proiessions Code,and my license is in full force and effect - �r,�L - - '- - � O ' y �j� `i.J License Number-a�Lia Clanss � �� �- n . . ... . .._ _ � O CoNroctor��Date �+ ��-+ / � �-� � . � 0 � ❑ I am exempr under Sec. ,. _ _ '� w Plan check fee o. � B.BP.C.(or rhis reason PERMIT ISSUING FEE S O SO z Dote: Sgnarore TOTAL FEE _ � ' � OWNER-BUILDER DECLARATION PLAN CHECK AFPUCAM I he�eby affirm�ha�I om exempt from�he Contracror's License , , , � low for the following reoson(Section 7031.5,Business ond NnME � �. Professions Code�: � ' ❑ I, ps owner of fhe property, o� my employees wilh ADDRESS � wages os�heir soie compensation,will do the work ond , the structure is not inrended or offered foi sale(Sedion CRv TEI.NO. , , ^Q 7044,Business and Professions Code). . . - � O b`J 1 - OWNER� 1 '� ❑ I,os owner of the propery,om exdusivety conrrocting - ' with licensed con�roclon�o construct ihe project(Sec- ADDRE55 �, ����'�.�& tion 7044,Business and Professions Code). �- �� � � � � � CONSTRUCTION LENDING AGENCY CITY - TEL NO. I hereby affirm 7hat there is o constroction lending ogency for Ihe performance of ihe work for which this permil Is issued - � CONTRACTOR' ,. '� ( • �$Q,�5. (Sec.3097,Civ.C.). � . . -.. - . .. . .. _ _. ADDRE55 . . - . . � .. ... . . _ _ . . tender's Name I � � Lender's Address - Cliv TEL NO.� .� . _ .. . . . . . . . STATE UC. � ' ' 1 certiiy rhat I fiave read this applicat�on ond sto�e thar ihe UceNSe No. C�A55- - � . obove information is corred.I aqree b tomply with oll Counfy � ' �� °�Q,2 Jr c=i ordinonces and State laws relating lo building mnsfruc�ion, � . _ . ._.. . .. �. ... -. . .- . O a' 2,_8.7 . ond h�reby authorize representatives of this CouMy to eNer . . � uQgqrfie a6ove•memioned propery for inspedian purposes. , SEE REVERSE FOR ExPLANATORY I.ANGUAGE _ _ �' . _ ,�� �-�-k�7 Signa�ure of Applicon r Agenl Dale �� ��� � ��� - � - - - � , . . � .�;- . ��. . ., . �. . � . . _.._ ., . ... .. .. . . . ���' '� ' � • INS�ECTOR'SNOTEs OWNER-BUILDERDECLARATION' ' .r . . :�!: ... . . � ,.. .. ,. .. . . ..,... � '� I horeby a`firm Ihor I cm exempt'fram the Comrecto�s � � 'r -"' '-� ' �' " License Law for�the tollowing reason (Seclian 7031.5, , :.� ; �- . . .. . .... . .. .__..... . .. ... ... _ _ ___. ... __ ...._ BusnessondPro : , � � ,�. . �, - ' '-:',-� - . Iessions Code)�Any dty or coonly whith .-� �.�, . � - � - - requfros o permlt fo mnstrucL olrer,improve,demo��sh; � � � � ' ' ` - " � � ' oc_Fepai�any�slruclure,prior lo.lts issuonce, also rn � ,� "' - • , �� - ____ quirestheoppf(cOnllorsuchpermit:tofifeoslgnedsfale- �� ' � , �- . -.. - ' ' '� ' ment fFaf he la Iicensedpursuanf fo fhc provisions of ihc � ` � � � � � � ' � � Conlrocfor's License Law(Chopler 9(mmmencing wllh � . i � � � � � � - � � ����"�"-�� � .� � '� � ' „Secffon 7000)of Division 3 oF thc,6uslness and Prolos- �- �sions Code)or fhaf he is exempt Iherehvm cnd fhe basis . � , � ,' I � - � � � � for fho alleged ezemp�ion. Any violction al Secfion "' � " ; . _.. ._ '' �' .,''�� � , , 7031.5 by any appficont lor a permif subjec�s Ihe oppli• .. . .__. . .__ -�--� --- . .._ . _.___. , ; . . . � - � � ., . . . � -- ' coni to a cfv(f penalry o/nof,more Ifion Hve hundred -- . _._ ._ , .. .. _ __._ _ . ._: dolfars(3500j.: . .. . . ' l� /� � ._ . ` .. .. .. .... ,i _ ,,�.�_ � _ _ , ❑I,as owner of ihe property will do the work,and . . ' ., , . , -" ?he structure is not in�ended or offered for sale. �. " i , � ��-- -�- -�-�-� - - ---- ��- -�� � -- �� � �� � � � � � (Sec.7044,6usincssendProfesslonsCode: iheConfrac- :�i� ,. ' tor's Licensc Law does nof apply fo an owner o(property � � � - - ' _ I .._ ' who 6vilds or improves fhereon,.and who does such . . . - � � work himself provided fhat such improvemenfs ore no� _ _ - - � - - � � iniendod or offerod for sale.H,'howovcr,dhe 6�ilding or � - � - - . . . . . improvemeM ia sold wuhin ana yoar of complotion.�he ; - . . -.- -.-. �� - -��-� 1 . . : owner6ullderwlll hovc fhe 6urden of proving thaf he did � - � � . � not build or lmprove for}ho purpose of eaic.) � -.._-..�,. .-. . - - .. . � '' ' ': ���' ��t�I,os awner of�t6c(pToPcrly,am exclusively mn- • , � ; ��acting Wi!h liccnscd cont'rocfori,to construtl the projecr � - � - - {Sec:7044)Business and PrcfessionsCqde�The Controc- . _ ' , . - �`for's llcense'Low does nof opply.fb 6n'olvncr of property � "---- � -- --- - - �� � -�-- who 6utlds or Improves fhereon,and who conlrads Ior � ___ �� ��'`� ' such�projects wlth a coniraclor(s)licensed pursucnl to - - - � ---the Canlrador's Clcense Law).� � � : � ' " I am exempt undcr Sec� � � � ' �� 8&P.C.for this reason� ' � ' � , '.- ' � ... . . . . � � � . ; � ' . � � � . . . . .. . : _ ' - . - .- '. - - ' t �, ,, ,'`.` ,,,`�� '.' ti- .. . Date ' , . � . ._. . . . .,r.. _ . � . . � ,� . . .. . , . . . _ . . .. _ ' . •.. .,:"�'. .., �J� :� T.� ._� . Owner ' � . . , . _ , . . . ; . \ _ . :.. ,, �, . -- "-- - - - - - _ �, _. ._. INSPECTOR'S NOTES —_._. � ... _�_�..��':1,1 . '. .- � . -" - . . . . . . . . . � ,. .,,� . .. _ ,_,c . .� . ..� . ., -. .. . .—._. . .., � � . . � . _. .`"' . — . ._ -. -�-.- ___ .. __.._ _ ._ .. . .. _ _ '� .. . .. . -. .�'�