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HomeMy WebLinkAbout1499A WORKERS'COMPENSA710N�ECLARATION �� � n � 1 here6y a(frrm that 1 have a certificate of�o�5e���a,6�f � APPLICATION FOR PERMIT I<< insure,or o cerrificore of Wo�kers'Campensation i�z��o��e, 76A�eac HEATING -:VENTILATING - AIR CONDITIONING Qr prc Hif)'ed mpy fhereof($ec.38 Lob/.C. � �E-8I8(REV:10/81�� ��N�/—y�'S� Company rI; � . . . . . , . ��O�D � COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. Certified copy is filed wilh the county building inspec• FOR APPUCAN7 TO FILL IN -- BUiIDiNG rion departmenr. � � � a�oRess £� „j� � �Q� � /� /G y� (PRINT OR TYFE ONLY� Do�e —A APPlimn J LOfALITv x�� NO. TYCE OF APPLIANCE OR E�UIPMENi FEE N CERTIFICATE OF EXEMPTION iROM RKERS' NEAREST COMPENSATION INSURANCE � . CROSS 57 (Thfs��efion nwd nof b�complel�d ff}ha work(nrolved by� ABSORM�ON UNIT,BTU OISiRiGi NO. VROCESSED BY �tho p�rmlt la Ior onv hundnd dollan(SI00)or�s�s.) qIR HANDUNG UNIT,CFM � I certify rhot in Ihe performonce of fhe work for which Ihis ��� � permit Is iesued,1 shafl nof employ any person In ony manner . � so as 10 become sobjeU to fhe Workers'Compensation Lows. 9DILER,BTU APpROVAlS OATE iN PEQ04'S SIGNAiURE Dafe APPIi[anl COMFRESSOR,BTU ROUGH ` ��^.,�'i,. NOTICE TO APPLICANT: If, otfer mokin9 ihis Certificate of VEN71tA710N SYSiEM � FINAI (,���� 0,/ � • Exemp�ion, you shovld became su6ject to Ihe Workers' �. Compensolion provisions o(Ihe Lobor Code,you must fonb- EVA70RATIVE COOLER VALIDATION wiih comply�wiih such provisions or ihis permit shail be deemed�evoked. J FURNAGE: FAU -GRAVITY LICENSED CONTRACTORS DECWRATION ( FLOOR aiU — � I hereby of(irm 7hot I am licensed under provisions of Chapter 9 SUSPEN�ED UNiT_ "- HEATER: WA�� '(cammencing with Section 7000)of Division 3 of the 8usiness } and Professions Code,and my license is in full iorce and e(fect. • � �� �,,,r ?s � � 0. License Number+�/�� Lic Closs C Zv ' � - � � � - ► �U .� c Contrad ofe �G'—�(.� �� � � d ❑ I om exempf u er Sec. W Plan cFieck fee �1 4 9,9 F N B.&P.C.fo�this reason PERMIT ISSUING FEE S /p S �• . • . •F3 �' Dole: Signawre TOTAL FEE y 75 ' J • •7475 OWNER-BUILDER DECIARATION FLAN CHECK AaPIICANi � � I hereby affirm�hai I am exempt from the Controcmr's License ► . • • �7 Q 7 Jr c=.� Low fo��he(ollowing reoson(Sectfon 7031.5, Business and NAME � - �Professions Code): � . �Q'��'Q�] ❑ I, os owner of the property, or my employees wifh �+DDRE55 wages as their sole mmpensation,will do tbe work and aiv TEL.NQ � the srructure is nor intended or oflered for sale(Seclion 7044,�Business and Professions Code). � , OWNER �� f.� �y �. ❑ I,as owner of the property,om exdusively contrading ru . with licensed contractors fo construc�the project(Seo ��� � � � tion 7044.Bosine5s Ond P/ofe55ion5 Code). nDDRESS CONSTRUCTION LENDING AGENCY � pTy 1 � , TEI.N . � . I hereby affirm thot fhere is p construclion lending oqency for �l � � �he performonce af�he work for which fhis permir is issued �pNTRACT ���' � � - -� - ► � (Sec.3097.Civ.C.). , .. . . . . . . . .. _. ADDRESS v7 �,� � . - . . . .... . � �- . . - . . Lender's Name � � CITYQ �� .TEL NO. � _ _ . , . lender's Address . � � - I certil ihat I have reod fhis a licafion and srore thal the SiArE tIC. . � y pp LICENSE NO. � CLASS �- ���- --�� � � . ._.. - _ _ . above informolion is correcf.I agree lo comply with all County , , ordinonces ond S+ote lows relatinq to building consrruction, . and hereby aothorize represenlatives oi fhis County fo enter � � � � - �� � ' � � � �� opon the obove-mentioned properry for inspeUion purposes. �SEE REVERSE FOR EXPLANATORY LANGUAGE . /b—/G_�r� �gnaiureofApplironrarAgen Da�e ' � ' �-� ' . �- - . � � ., ,.. , . .. .._ ` "-' ' ItiS�ECTOF.'S HOTES - OWNER-FSUILDER DECLARATI4N , � •. . . � l . . � , _ � - •- �„ - ��-I Fere6y affirm lhai I am exempt from th Contractor's �" ' ' ��` License Law for the foltowirg reason (Sedion 703I.5. .'--.__..__...._....._.._.... ..._ . ......._...._.._ _... .._. ._... .. .. . . .. ... . . .... . . . . ..._.._... .._. 6usinessandProfessionsCode):Anycilyor�auMywhich . ��..�- � �,.�'-'� . � � � reqoires a permH to consfru</,ol�cr,Improve,demolish, � � ----- �- � � � � � ' '-- -' - - � � � ' or repcf�ony skudure,prtor ro us lssuance. also re- t 1 . .. . ��t�� ... � . . . . . -. .qvires}heoppliconfforsuchpermf�foftlebsignedsfale- ' ' \ ;--` . - � . ' � , , - ' � ' mon�thal he fs flcensedpursuant to fhe provlsfons of fhe �� � � Conlraclo�'s Llconse low(Chopfer 9(mmmendng wllh :� �':.�- ,`.�.�,�. `\ ' � �..,• ..'.� �,..,�� . . ...... ' .... � .Secflon 7000J oi Division 3 0(Ihe business and Froles- � \\ � �, � � slons CodeJ or fha�he is exemp�rhrrefrom and 1ho basis � , - ' . .. . . lor the�allrged ezempt on Any violatlon o(SecHon . . 7031.5 by any oppliconf lor o permll subjech,lhc appli- .. ._ . ._._._r _._� ._ ... _ � . � � � . . � � � -- - � � can�to a civtl�penaGy ol not.more than(Ive hundred - _. _ _ - i doua�s�ssoo�. � � _ - �- :: .-� � � '� ❑I,os owner of thc property will do thc work,and , _._._. _ . . ._ . .....___ .. . � . i � .' , . .,. .. . � . �he structore�s not inlended ar olfered for:ole. , --- - ---- --- � - --� � � ---- - � - � � � � � � (Sec.7044,6ustness and Profeeslons Code:� The Contrec� . � , , � . for's L�cense Low does nof epply fo an owner of proacrty ��"� - -� �� � .., - ' who bullds or�fmprovcs thereon, and wha does s�ch . . , . � . . ' work htmseff pro�ided fho�such improverocnls arc nar • . - �� � � � inlended or o(7erod(or sala.I(,howev=q fhe bullding or . .. . . . _ . -� Improvemanf Is sold wilhln one year ol<omplefion,}hc � � ' - --�-' -� - �owncr6uilder wifl hove 1he fiurden of proving fhai he did � � . 'nol bu�fd or fmprove!or tho purpase o/eale.J�� ' � , � � - � —�I,os owner of ihe properfy,om ezcfusively con- • � � � � tro;ting with licensed controcfors�fo coRsirod Ifie project j � --� - -- -� � - �� .�Sec.7044)Business and Frofessions Codo:Thc Con)roc , � . � Yor's License Lnw docs nof apply fa�an�owner o1 properry Y ` . - - - - . - w6o 6ulfds or Improves fhereon,and who confrocfs(or such profecfs witfi a confrac�or,(sJ f�censed pursuan�fo � -. • . • • j: , .. . . ; � �� � . � . . . .. . . - 1he Canfrador's Lkensc!aw). . . ... ..... _ ., , •. � �, -. . . �� � , � ... " . . . . .. . _. � � � � � � I om exempt undei Sec. , — _`.�- 1 �... B E P.C.{or lhis reason .. . . . � ..._. . _. . ., . .. -' - - � . . . � Date � � __.-- . ... � . �, . � . . '.� .._ Owner . . INSPECTOR'S NOTES -- � - � � - � �� � ... . ... . � . .. .....:. . . . . . '... , . . . �. j'