HomeMy WebLinkAbout1500A (8) WORKERS'COMPENSATION DECLARATION APPLIGATION FOR PERMIT �7 �
I hereby affhm�hat I have a certifimte of consent to self � �7,�7/(1
' sure,or o certifimte of Workers'Compensation Insuronce, - � / U
� t i d co y �q qqqf'''(Sec.3800 lab.C. 76A3b7C HEATING - VENTILATING - AIR CONDITIONING
���,��. ���y �E.818(REV.10/81) . . .� .. - . . . . .
�ol�cy No. �Compan COUNTY OF LOS ANGELES � BUILDING AND SAFETY �F D .
Certified copy is hereby furnished. ��
ertiNed copy is filed with county buildin9 inspeo- FOR APPLICANT TO FILL IN euaDwGq /�
tion departmeN. � (FRIM OR TY7E ONLY�. N�DRESSu{D� �� ,,,,�//7
Dare�I G'IG��Applican � �� LOCALITY�� ��� .�
NO. TYPE OF APPIIANCE OR EOUIGMEM FEE
CERTIFICATE OF EXEMPTI FROM WORKERS' NEnRESr
' COMPENSATION NSURANCE - � �ROSS Si.
(Thi:satlfon nr�d nof b�complrt�d 1(Ihr work involvad by ABSORPTION UNIT,BTU OISIRICI NO. PROCESSED BY
fha permff Is for ono hundrod dollars(5100)oI Ioss.� qIR HANDLING UNIT,[FM ��
I certify�hat in Ihe performance of the work for which ihis 2 �
permil is issued,I sholl not employ any person in any manner gOaER,B1U
so as to 6emme subjed to Ihe Workers'Compensalion Laws. nrPaovnis Dar[ WSPECtOR'S SIGNAtURE
Date � �oppiicont COMPRESSOR.BTU ROUGH l-{�$� -
N07ICE TO APPLICAN7; If, pfler moking this Certificate af VENTIIATION SVSTEM FINAL `'��—c• �—�
Exemption, you should bemme subject to Ihe Workers' .
Compensation provisions of ihe labor Code,yoo most torih- � EvnvoRnTIVE coO�ER � VALIDATION -
with comply wilh such provisions or fhis permil shall be
deemed revoked. � � FURNACE: FAU RAVITY - �
. LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I hereby offirm fhat I am licensed under pro�ision5 of Chapter 9 SUSGENDED UNIT_ - �
HEATEF: WAII '
� �(commencing with Sec�ion 7000)of Division 3 of fhe Business
and Professions Code,and my license is tn full force and ef(eU. . � � - � ' �"
/� a
Litense Number�`��G��� Lic.Closs �� ��� / s S , U
C
Contrac v � � Dafe �U`��—�7 - . � O
❑ 1 am ezemp�under Sec. - . , _ w
Plan check fee y
� 8.8P.C.for this reason� - � fa J � �� S Q O F Z
PERMIT ISSUING FEE S
Da�e:
Sgnature TOTAL FEE �J�/ S �j• • • • •$
OWNER-BUILDER DECLARATION PLAN CHECK APPIICANT I • • �G.rI Jr
I hereby atfirm Ihat I am exempt from the Confrocfor's license � � �.��.�5=
Law for Ihe following�eason(Section 7031.5,Business and NnME � � , �
Professions Code): � ' � r�
� ❑ I, as owner oi the property, or my employees wilh ADDRESS � Q G� ��''I
- woges as their sole tompensa�ion,will do Ihe work ond �
the struUure is not inrended or offered for sale(Seciion Ci7V TEI.NO.
7044,Business pnd Professions Code). �� � �
OWNER
❑ I,os owner of 1he property,om exdusively coNraUing
wiih licensed coNraUors to consrruct the proje[I(Seo- � MAII � �
tion 7044.8usiness and ProFessions Code). AooaeSS �. �
CONSTRUCTION IENDING AGENCY CITY G � iE�.N - ' '-
. I hereby alfirm that there is a conslruc7ion lending ogency for ,
the performance of the work for which this permit is issued CONTRACT ' - � � � -
(Sec.3097.Civ.C.). -- . .. .. . ..
� ADDRESS �� �-�� . ' .. --� . . ' . . . .
lender's Nome
��Ty TE�. o. 99s �ov
lender's Address �
STATE q �.i LIC �/
I certify that I have read this applica�ion and stare that 1he LiCENSE NO��/ ! CLASS- �-L�� Z� . . ._ . . . .
o6ove information is carrect.I ogree lo comply with all County -
ordinonres and Slate laws relafing to 6vilding construction, �
and hereby avihorize representatives of this CouMy to enter � - - � � �� � � ��
upon the above-men�ion d prope.ty for inspeUion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
(s-c.-,--�-. /U-/G-S 7 _ .
�gnaWre of ApPlicanr or Agenr Dale . .. . . . .-. . .. ... .. . . .. _ . . . .
• IN7�ECTOP.'S NoiEs OWNER-F3UILDER DECLARATION
� ' 1 hore6�affirm Ihat 1 am exempf from the Conirp;tor's
- -� �- �� � ' '' �� ��' ' ' ' � License Low for th� following reason (Secfion 703�.5,
..... ..__... ....._.... . ... ._._..,,._.__ ._ ..... ._.. ._ __... .'_'..._: _. .... .. ..._..._... �
•"' ' � """"" BusinessondProfesslonsCodeJ�Anycltyorcounlywhich
� " � � . ": � � - , requlres epermll foronstruct,alfer.7mprove,�demol/sh.
� --- " �� � ��'- . - � - . - �- �- � er repoir��any slructure, pNor�te,lts Issuonce, also re�
�� \ � !{ "�� � "•.,". , �� � ' ,"- . ... _ ,�, qulresiheopplicanl(orsuthpermi�folilcaeignodstale-
. --'-',- � � p��.--- - �� � � - , . �' - � - menh Ihat heJs Iicensedpursuant to fhe provlsions o1 fhe
. ;.y•i�� � . . . Contracfor's L)cense Low(Chopter 9�(commencing wffh
'-� " -� � 5 ', ��� "" ' "��\' _ " � " _� - � Secfion 7000)of Division 3 0(�hc Bvsiness and Pro(es�
� 'slons Code)a�thol he Is e.empf iFerefror*t and ihc 6asis
, . ' � � . _. '�' � - for }hc.olleged exemphon� Any volotion of Section
� . . ' � � � .._. � � .J031.5 by ony appficanf for a�permil subjects�the�oppli-
:�---..___.___ ._.. . . . .
., , � , . � .. ,� .caN fo a dvlf penplty oi nol more�than flve hundred
_._ __._. _ __.__ .__. . . . '... -� dolfcrs(5500).� ,
• -i � � � � -- �� �- ' ❑I,as ownEr of�he property will do the work,ond
� ��� �� � - � � - � - � - �� � . . �hc struUure is nor intended or affcred for sale. ''
. .��. ,- . ,'.,'. . ,� ; � �� . � . , . .
� —.� --� � �� -----� -- -- -- �� - � -�-� ; � . (Sec.7044,Business andProfesslens Code:-ihe Controc-
,. . , dor's Licenselow doos not opply fo an ownero(properfy
� .�, ..
' � " � � - � � � � who butlds or Improves lhereon. and who does such
� . work hfmscl/prov7ded�hot such Improvemenis ore nol
. � - � � infendedoro(ferodloriafe.H,however,�hebuifdingor
� A
� . � . .. .__. . .. , � ;.�7mprovemen�is sold wlffifn one year of compfeflon,the
�' .. � � - - -.:. - . ! �owner•builder wilf havc Thc 6urden af proving fhal fie did
� - , . .� . . � not buftd or Improve(or�he purpose o!sole.) �
'��,. ,,. . .,' , .. . . .
..� - ',�1,os owner of thc,property,om exclusively con-
. . , � " traciing with licensed mntractors to�mnstruct ihe p�a'��U
� . ' -� - _ (SCC.�O44J BU51lIB55 OOd Pf0(PSSIOns Codcr�The Contrao
. � tor's Licenselow does not apply fo an owner ol properly
�- � who 6vilds ar Improves fhereon,and who confracts for
II. ; r,,. , -_ _.. - _ _ „ _ -- .�- .. . _� svcR projecfs with a mntractor(s)ficensed pursuanr�o
�-fhc Confrador's liconse Law).� .
� - �, � . . _. . .
�.. . . . . . .. .. _ ._ . . ..
_ ,_.� ... _ ... . . _ _ . , .
' ' `�- � ° � ' ' - ' I am exempt under Sec.��
., . .1�1 . � • . . . . � . , � . , � .
� B E P.C.for this reason� �
� ! ::'� I �
I ,
j-: - - --— - . Date , . . , , '
. I _. .. , .. . '- � . Owner
..I � .___.__._. . ... .. . . ., � .. . . . .. . . ..
; i -- . . . . . . . . , .. . � . , .
INSPECTOR'S NOTES i