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Home My WebLink About1701 CLIFFBRANCH DR (5)WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affkm that I have o certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, '-or 7oA364C HEATING - VENTILATING - AIR CONDITIONING a certified copy thereof (Sec. 3800, Lab. C.) - CE-818 (REV. 10/81) - - - Policy cy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ,ion department. - (PRINT OR TYPE ONLY) ADDRESS 0 DateApplicant LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST COMPENSATION INSURANCE CROSS ST. ' (This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PxocE5SED e' the permit Is for one hundred dollars (f100) or less.) 1 certify that in the performance of the.work for which this AIR HANDLING UNIT, CFM % O / permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compe�nssJation Laws. BOILER, BTU APPROVAts DATE It • Data 4A Applicant ./ COMPRESSOR, BTU ROUGH NOTICE YO APPLICANT: If, after making this Certificate VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ALI ATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU _GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 __ SUSPENDED UNIT HEATER: s (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code, and my license is in full force and effect. 0 � Llcense Number- I I Z.OZ�J tic, Class_6 , V 1 ZEGISTER / / ZY Contractor Dale_ ® I am exempt under Sec. Plan check fee B.BP.C. for this reason S PERMIT ISSUING FEE; U S-V Signature 7 V TOTAL FEE OWNER -BUILDER DECLARATION 47 PLAN CHECK APPLICANT r�r I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME �� r ► Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section NO. l ITY TEI. % -7 O ElfRa 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL ADDRESS Q •� tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR �? (Sec. 31N7, Civ. C.). - _ ADDRESS i©741 Lender's Name CITY TEL. NO. 977/40 86 Lender's Address I certify that I have read this application and state that the TE L1C. LICESTANSE NO. ("LbZ 3 CLASS - 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 upon t e above- oned�property for insp ctia Purposes. _ %3 s3 .SEE REVERSE FOR EXPLANATORY LANGUAGE Signolure of Applicant or Agent J41 SIGNATURE ;S907.3A I • ••2225 •••22.251v 0404,-85 INSPECTOR'S NOTES OWNEP,-BUILDER DECLARATION' , - - -I hereby affirm that I am exempt from the Comracior's ' License Law far the following reason (Section 7031.5. Business and Professions Code): Any city or county which I -- - - requires a permit to construct. alter, improve, demolish, or'repoir any structure, prior to Its , issuance. also re- _ - _. _ , • _ ,. _ - ..gdires the applic&nt for such perrntffoTile a 3lgned state- ' - - - men? that he Is licensed pursuant to the provisions of the Contractor's license Low (Chapter 9 (commencing with • " - ' - - - - - Section 7000) of Division 3 of the Business and Profes- _ sic- Code) or that 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 appli- - - cant to a civil penalty of not more than five hundred ' --- - - dollars (S500)-: - - - - s _ _ ❑ I, bs owner of the property will do ibe work, and - - the su.cfure is not intended or offered for sale. . - - - - - - - (Sec- 7044, Business and Professions Code: The Contras - for's License Low 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 sole. If, however, the building or ' Improvement Is sold within one year of completion, the - owner -builder will have the burden of proving that he did t '. not build or improve for the purpose of sale.) • 'I•-! :. _'l�,;-; �, .t a ti �, ❑I, as owner ofthe propefty,amexclusivelyco- tr. Zhng with license contractors'ro construct the pro;ect ;ZSec.t7044) Business and erofessians trode: The Conlrac- - tor's License Law a cei nof'opply tc on owner of property _ - who builds, or Improves thereon, and who contracts for such projects with a contractors) licensed pursuant to _ ' the Contractor's License Law). - \ - -�� I am exempt under Sec. B & P.C. for this reason ' _ .. ...... t� Date Owner INSPECTOR'S NOTES