HomeMy WebLinkAbout1625 BEARS DEN RD (7)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.
BAP.C. for this reason
Dote:
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm That I am exempt from the Contractor's License
Law for the fallowing 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 tinned operty for inspection purposes.
e, i3 ,2 7
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
nISTRICi No.
/
PaocessEo sY
AIR HANDLING UNIT, CFM
BOILER, BTU
APOROVALS OATS INSVECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
VENTILATION SYSTEM
FINAL
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 WJ
PLAN CHECK APPLICANT �� 1+ 2 2 2 5
NAME ► • " + 2 2 2 5'.
ADDRESS 02 1 3 r 8 7
CITY S TEL, NO.
K .
OWNER _..I H/i.xr./�,
TEL NO. d4t;/ 7�
CONTRACTOR �tti/f1S ,
ADDRESS
CITY TEL. NO,
SEE REVERSE FOR EXPLANATORY LANGUAGE
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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 licansed pursucnt to the provisions of the
Contractor's License Low (Chapter 9 (commencing with
Section 7000) of Division 3 of the Easiness 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 ($500).:
❑ i, cs • o or of the propery will do the v ork, and
the structure is not Ireooded or offa-ad for sele.
(Sec. 7044, Susinass and Professions Cado, The Contras
far's License Law does not apply to on owner of property
who builds or improves thereon, and who does such
work himself provided that such improvements are not
intended or offered for sale. if, hovreverr the building or
improvemc-nt is sold within one year of eennpkfisst, the
own —build —will have the burden of provtng that he did
not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively can
-
i-acting witl,. licensed contractors to construct the project
jSec. 7044) Business and Professions Cody: The Centrec-
fe, License Law does not apply to on owner of property
who builds or Improves thereon, and who contracts for
such projects with a contractor($) licensed pursuant to
the Contractor's License Law)_
I am exempt under Sec.
6 &. P.C. for this reasu
Owner
INSPECTOR'S NOTES