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Home My WebLink About0712A WORKERS'COMPENSATIONDECIARATION AppLICATION FOR PERMIT � � � I here6y affirm that I have a certificate of consen�to self insure,or a certificate of Workers'Compansation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a cerrified copy ihereof(Sec.3800,lab.C.) - . � . CE-BIB(REV.10�81) . P❑olicy No. Compony - � Certified copy is here6y turnished. COUNTY OF LOS ANGELES 6UILDING AND SAFETY � Certified mpy is filed wifh the county building inspeo- � FOR APPLICANT TO FILL IN - sU4D�NG r . fion departmeM. (PRINT OR TYPE ONIY) � P.DDRESS �� t..+� Dote Applicant � LOCALITV . NO. TYPE OF APPLIANCE OR EQUIPMENT . FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSUR.4NCE CRO55 ST. - (Thic wctton n�ed not ba compl�fed if tho work�nvolv�d by ABSORPTION UNIT,BTU DISiRIR NO. PROCESSED BV � 1ha permM ts for one hondred dolbn(5100)or Isss.) AIR HANDLING UNIT,CFM 1 � I certify ihat in the performonce of the work for which this !Q � permit is issued,I sholl not employ any person in any monner � so as ta�6ecome subjecr�o the Workers'Compensation Laws. ��ER,6TU araeovnis onre � irvsveaox�s sicNnroae „�,I�� COMPRESSOR,BTU � 'O C) ROUGH �Date�Applic � • NOiICE TO APPLICANT: If, after making this Cer' e of yENTILATION5V5TEM FINAL d yy Exemption, you ahould become su6jed fo ihe orkers' � , Compensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER � VALIDATION � with comply wilh such provisions or this permit sholl be deemed revoked. fURNACE: FAU_GRAVITY -tICEN5E0 CONTRACTORS DECLARATION FLOOe siU � 1 hereby affirm fhal I om licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ �(commencing with Section 7000)of Division 3 of the Business WA�� and Professions Coda,and my license is in full force and effecl. 0. � . License N�mber Lic.Class � , V K Contractor � Date � ❑ I am exemp�under Sec. . w Plan check fee N B.&P.C.for this reason pERMIT ISSUING FEE S � ? Date: Signarure TOTAL FEE � OWNER-BUILDER DECLARATION PLAN CHECK APPtICANT I hereby affirm�hat I am exempt from the Contractor's License , , Law for Ihe following reason(Section 7031.5, Business and NAME Pr fessions Code): F O 7��2 A I, as owner of Ihe property, or my employees with ADDRE55 � #-�� a wages as their sole compensation,will do the work and � � � the structure is not intended or offered for sale SeUion CiTv iE�.Np.. 7044,Business and Professions Code). ,( � �,� �2�,5� OWNER / �• • •20,,rjp= ❑ I,as owner of�he properly,am exdusively comraciing C� r�'• v D�� c� with licensed confraclars lo conshoc�fhe project(Sec- MAIL ' ' fion 7044,Business and Professions Code). ADDRE55 0 5.1 4—8 5 CONSTRUCTION LENDING AGENCY � Giiv TEL NO. I hereby affirm lhat there is a consirucnon lending agency for ►� �he performonce of�he work for which this permit is issoad CONiRACTOR �J�,/� � (Sec:3097,Civ.C.). � , . . - . ADDRE$5 � � Lender's Name � CITY TEL NO. - -Lender's Address � � 1 certif ihat I hove read this a lim�ion and state 7hot�he. S7ATE L�G � � . y pp UCENSE NO. C1A55 above informa�ion is co�rect.I ogree to comply with oll Coanty. � ordinonces and S�ate laws relatinq to building construction, ❑nd hereby aulhorize representatives of�his Coumy to enter � � � pon rhe o e-mentione prope for' pection porpose. .� SEE REVERSE FOR EXPLANATORY LANGUAGE ��p�c.�� 6—/5��.� �Signoture of Rpplicanl or Ag C Dale - � . � � ' IW CTOR'S NOTES OWNE�-6UIlDeR DECLARATION - � I hereby affirm ihot 1 am exempl from the Conira«or's ' � ' � � License Law for the followinc� reason (Section 703L5,� � '-� � �� ' � � Business and Prolessions Co�e,;:Any cliy or counry whlch . . � , - . requires a permit io consrruct,alter,improve,demolish, � - " � � � or repcir ony strutlure, prior fo i�s issuance, also re- � quires ihe applitant lor such permit to lile a signed stote- i � � - �- -� � menf ihaf be is licensedpursuanf fo the provislons o/the _ ` � � �� Conirodor's Licsnse Law(Chap+er 9(commencing wlfh �� -�., - Sedion 7000)o£Division 3 a/ihe Business und Proies- � sions CodeJ or hhat he Is�exempt fhereirom ond the basis . , , � � � � - � � !or the olleged e mpiion. Any violation o/ Seciion ._. . . , 7031.5 by any applicant�or a permif subjects}he opp14 �� cont to o c1Wl penalty of not more �han live hundred ' - ' � - � , doflors(SSQO).: _ � � � � � � � � , �t,�owna-pf ihe prope�ty wi4�do�ihe work,nnd � . � �he siructure is no�in+ended or offered for sale. � . � � -- � � (Sec.7044,Business ond Prolessions Code; The Contrar � ' . , . tor's ticense f.vw does nof apply lo an owne�of property , � � ' � . who bullds or Improves lheraon, cnd who doe5 such � . work himsell provided thoi such imFrovemenfs are no� � � � . infended or offered for sale.Il,howeve�,the buildrng or . improvemenf is sald wilhin one yzor of complefion,1he - - � - ownerbuilder will have fhe burdan of proving thol he did � no�build or improve(ar the purpose of safe.) � �I,as owner of ihe property,am exdusively con- . �'ractinq with licensed toniradors to cons•ruct ihe projec�� ;Sec 7D44)Business ond Professions Code�ihe Confror tor's License Low does not opply to an owncr of property � � who builds or improves fhcreon,er.d who mntrads for � such projects with a contratlor(sJ licensed pursuanr to _ � the Contractor's License Lawl. � � ' I am exempf undcr Sec. � �� B&P.C.for ihis reason _ . . , . .�, �, .. Date . . _. ,` \ '�l . . . - ' � _ � �� - . . - Owner - INSPECTOR'S NOTES f \ � J ,, 3 � ,.