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Home My WebLink About1625 BEARS DEN RD (3)VVFMRERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self irtsare„ or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspec- tion department. Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the work Involved by the permit Is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shad not employ any person in any manner so as to become subject to the Workers' Compensation L Dote -<Applicant �7�� NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 '(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number Lic. Class Contractor Dote ❑ I am exempt under Sec. B.&P.C. for this reason Dote: Signature OWNER -BUILDER DECLARATION 1 hereby affirm That I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): I.L7 I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 70", Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter the above -me Tlaned operty for inspection purposes. Signature of Applicant or Agent Date APPLICATION FOR PERMIT 76A364C HEATING - VENTILATING - AIR CONDITIONING CE - 818 (REV, 10/81) COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN (PRINT OR TYPE ONLY) OUILDING ADDRESS /(� ZS /'FT LOCALITYr-E� NO. TYPE Of APPLIANCE OR EQUIPMENT FEE NEAREST CROSS ST, ABSORPTION UNIT, BTU DISNICT No. / / PaocessEo sY AIR HANDLING UNIT, CFM BOILER, BTU APOROVALS OATS INSVECTOR'S SIGNATURE COMPRESSOR, BTU ROUGH VENTILATION SYSTEM FINAL 61� I— EVAPORATIVE COOLER VALIDATION FURNACE: FAU_GRAVITY FLOOR BTU HEATER: SUSPENDED UNIT WAI I Plan check fee I :F 5 9 7, h A PERMIT ISSUING FEES lo 4-0 # is TOTAL FEE UJ PLAN CHECK APPLICANT �� 1+ 2 2 2 5 NAME ► • " + 2 2 2 5'. ADDRESS 02 1 3 r 8 7 CITY �� Ss TEL. NO. OWNER ,^ ,,....� Fl/�,— //Li` C..CJ��9'mN74y ff- TEL NO. dy/ 7 � CONTRACTOR �tti/f1S , ADDRESS CITY TEL. NO, SEE REVERSE FOR EXPLANATORY LANGUAGE d O 4J as O V a 2 1 TOR•3 NOTES — OWNER -BUILDER DECLARA11ON ' I hereby affirm that I a .xempi from the Contractor's License Low for the following r n (Seefion 7031.5, Business and Professions Cod.): Any city or county which requires a permit to construct, alter improve, domohsh, or repair any structure, prior to its issuance, also re- quires the applicant for such permit to file a signed state- ment that he Is ticansed pursucnt to the provisions of the Contractor's License Low (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profes- sions Cock) or thot he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the oppii- cont to a civil penalty of not more than five hundred dollars ($500).: ❑ i, cs • o ar of the propery will do the v ork, and the structure is not Ireooded or offa-ad for sele. (Sec. 7044, Susinass and Professions Cade The Confroc- far's License Law does not apply to on owner of property who builds or improves thereon, and who does such work himself provided that such improvements are not intended or offered for sale. if, hovreverr the building or improvemc-nt is sold within one year of eennpkfisst, the own —build —will have the burden of provtng that he did not build or improve for the purpose of sale.) ❑ 1, as owner of the property, am exclusively can - i-acting witl,. licensed contractors to construct the project jSec. 7044) Business and Professions Cody: The Centrec- fe, License Law does not apply to on owner of property who builds or Improves thereon, and who contracts for such projects with a contractor($) licensed pursuant to the Contractor's License Law)_ I am exempt under Sec. 6 &. P.C. for this reasu Owner INSPECTOR'S NOTES