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Home My WebLink About1701 CLIFFBRANCH DRWORKERS' 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 DISrRicr NO. v4ocE5SED B' 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 ,o 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 iZ EGfSTER / / ZY Contractor Dale_ ® I am exempt under Sec. Plan check fee B.BP.C. for this reason Oat S PERMIT ISSUING FEE; U S-V Signaturer 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 �� t ► 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. SITY A ICU—TEI. % -7O Rf- 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 8b Lender's Address I certify that I have read this application and state that the STATE LIC. LICENSE NO. (�b'i 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- n lonad�prcperty far inspe3ctta purposes- /s3 .SEE REVERSE FOR EXPLANATORY LANGUAGE Signolure of Applicant or Agent J41 SIGNATURE ;S907.3A I • ••2225 • • • 22.25iv 0404,-85 INSPECTOR'S NOTES OWNEP,-BUILDER DECLARATION' , - - -I hereby affirm that I am exempt from the Comracior's ' License Law for 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 applicant for such perrrttffoTile a 3lgned state- ' - - - men? that he Is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9 (commencing with • - ' - - - - Section 7000) of Division 3 of the Business and Prate, _ sions 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, as owner of tho property will do ibe work, and - - the structure is not intended or offered for sale. . - - - - - - - (Sec- 7044, Business and Professions Code: The Contras - for's License Low does not apply to an 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.) • 't •-! :. _' l � ,; -; �, .t _ } .t'a ti �, ❑ I, as owner of (he propefty, om exclusively co- tr. Zhog with license contractors'ro construct the pro;ect ZSec.1,7044) Business and erofessians Lode: The Coolrac- - for's License Low ecei nof'opply tc on owner of property _ - who bullds,or improves thereon, and who contracts for such projects with a contraotor(s) licensed pursuant to _ ' the Contractor's License Low). - ` - -�� I am exempt under Sec. B & P.C. for this reason ' _ .. ...... t� Date Owner J - r s ` • s - INSPECTOR'S NOTES