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HomeMy WebLinkAbout1503A � WORKERS'COMPENSATIONDECIARATION� , APPILICATION FOR PERMIT� � I hereby affirm that I have a tertificate of consent ro self � )]�,�f� - insure,or o tertificate of Workers'Compensotion Insorance, � � .- . . � 7 � � ert'fi d copy e�e f(sec.3e ,lab.C. �en�eac- . � ,;;:"HEATING - VENTILATING - AIR CONDIiIONING . � �'� `�{�j� �,,/ � CE-B18�REV.10/81). . �_ _.._.... .:. '... .. .._..... . . I � Po if c"y Nb"' r y ��Compqn COUNTY-OF LOS ANGELES BUILDING AND SAFETY �3G[�%(> � ❑ Ceriified�copy is hereby fomished.'� � � - - � - -� � � . � �Certified mpy is�filed with the county building inspec• � �� - �FOR APPLICANT TO Flll IN� �� -� � euuowG p �� � on depanment. . � qooaE55 aQ �j J" [�...���'oj'� �� . � / ` �. —}f-� �PRINT OR iYPE ONLY)� � - DatelU����7�7APPIicant �'^�K � IOCALITY � �tC�J NO. TY�E OF AGPLIANCE OR EOUIPMENT� � . - FEE �J � . � � CERTIFICATE OF EXEMPTION FROM W KERS', - �- � � NeneE57 � -� �- COMPENSATION INSURANCE � -�- CROSS ST. �Jjj � ', _ �TIIIS fYCti011 IIiY/I If01 bQ COTPI�I�f�I{}h!WOII(IlIVOIY@fI bY - ABSORPTION UNIT,BTU DiSTRICi NO. PROCFSSED BY }he parml}is for one hundrad dollars(5100)or loss.) � ' � `��� � I cerfi{y ihaf In�ihe performance ofdhe work for which fhis AIR HANDtING UNI7,CFM� ' � permif is issued,I sholl nol employ any person in ony manner � gOILER,BTU� � � so as to become subject to Ihe Worke�s'Compensation laws. .. nvvaovnis OATE � INSGECTOR'S S�GNATORE D6te � - � epplimnt � � COMPRESSOR,BTU � ROUGH '�`L(17t}'p � NOTICE TO APPLICANT:�If, after making.ihis Certifitate of - VENTItATIONSYSTEM � FINAL �08� �, Exemp�ion, you should 6emme subjecl to Ihe Workers' . . . � - Compensalion provisions of ihe Lobor Code,you musf forth• � EVAPpRATNF COOIER . � � VALIDATION � � , wilh comply�wilh such provisions or this permit shall 6e � �. -�deemed revoked: � � � ' � � � � FURNACE: �FAU GRAVITY � � � - � . LICENSED CONTRACTORS DECLARATION- � FLOOR BTU � � ��. � � I hereby afFirm tha�I am licensed under provisions of Chapter9 SUSPENDED' UNIT_ - --� � - . � HEATER: N,A�� � '�'(commencing wNh Section 70D0)of Division 3 of the Business ' � and Professions Cade,and my license is in(ul I force and effecL �j� -- • - -- �,�- �-- �l; --S- , . } .. � aL9y�G � e-zo �3 � a License�Number Lic.Class � � ���-���- - !— , . V ��, Contracto -�^—�Date �O�G"�"7 . . .. .. . .. '. .. . . �� - - � � . O . V ❑ i om e.emP+o�de�5ec. Plan cfieck fee �1 5 Q 3 A a ' N B.BP.C.for this reason pERM1T ISSUING FEE s ? � Dare: � , D S� . #• • • . •& , Signature TOTAL FEE 7 S � OWNER-BU�LDER OECLARATION - PLAN CHECK A7PLiCAN7 . , . � � �7 Q.7 5 ' . I hereby affirm that I am exemp�from the Contractor's License , � � �7�7 -Jr� . Law for the following�eason(Sedion 7031.5,Business and NAME � ' . . � ' - ', - Professions Code): � � � �' -� ' � ❑ I,�as owner of ihe property, or my employees�wilh �+DDRE55 _ � " _ � � a 2�—8 7 . wages as their sole mmpensation,will do the work and� �� CITV TEL.NO. ' � � Ihe slructure is no�intended ar offered for sale($ection � � ., . � 7044,Business and Professions Code).. � � , � � - � - � . . . . OWNER � . �.. ❑ �I,as'owner of the property,am exclusively coNmcting �i` . � , with licensed coMractors to conslruU Ihe projett(Sec- qDDRE55 � e- - � ' . tion 7044,Business and Professions Code).� - � � � �.. CONSTRUCTION LENDING AGENCY �� ciiv -- �� � �ht. :�� "" ' '�-���'��' � ��� I hereby atfirm that ihere Is a construction lending ogency for � , � � the performance of the.work for which this permit is issued � CONTRnR �-�"� "- �- '� - - - '� (Sec.3097,Civ.C.�. .- . - � . �.. . ._.., ,., _ , . ' . ADDRESSa3 . . • '. .._.__. . -,:.��, ��.,� :'__ '' _ "_' - 'Lender's Nome i . .. ._. . .- ----- : .. . . . _ � . . � � dTYQ� .__. _7 .NO./l OYI �) __ _. _... . . . . .. . '_. . .. . _. ._ _ .._ �� Lender's Address � � � � . . STATE G - IIC. �o . � I certify that I have reod this opplicotion and srote iha�the- LiCENSe NO.� � /�--- �� -.CLASS��{�--2.� �� �-- - - -- . �'. . . . .._ _ . . _... .-----..__ _ _ .._.. _.. , above informotion is correct.I agree�o comply-with oll Counly. . . � � ' � ' ordinonces ond$late laws relafing ro building construction, ... ... .. . . ' ' and hereby authorize represemaiives of this Couroy to enter . � .�� � ��' � � ����� �� � � � "� �� � -� '- . � upon the ahove-mentioned properry for inspection purposes. � . SEE REVERSE FOR E%PLANATORY LANGUAGE. .-. - �� . . .. �. _ .. ... .. _..... .. . _. _ . .. _ . .. ... . . _. . �. vCd � /G���'�� 7 � . � . - . � � � Sgnature ol AppLcuni�or Ag t � �ate . . . . . . _ _ .. _ .. __ �, ._.__'_'_'._... _ . . _.._.__ ....__ .. .... .. , . . . . . � � . � I . . : . . .. •�.�x� ..... � � . . .. . . ... s� ,.. , .. . ,� . � ,� . .. _ . . I i::V . , r . � �''i� ti't�`.;�" ;i,' . �: .,,,..:. : . . " : : _ ' , OWNER-6UILDER DEGLARATION . IN3PECTOR'S NOTES y�1 '� 1 \�\i:� \`,�� ' \ `� ,�`�, "1 hereb�+'affinri�tFat I am�oxompt from tFie Conirac�or's .-(,1`.y1;. f'�_.. .C::; .•.. . .t� - - - •. Litanso Law for�the follow'nq�reason�(Secllon 703L5. � __._��...,.,.___....___._��'.I_____......_'..'__.._____._... ._-.._._.__._..._.....___...___'..�-� BusinessandPro(osstonsCode:M cil orcoun! whicb ' j _'_.Y',"..� _ ) Y Y Y ��1 _�� ,,� �� � i� � ��<<� .r . ' � - „ , "��r quirezaperm�ftoconstruct,oltrr.tmprove�,�demollsh, . � - -� ------ --"" �- '� � � t or repolr_any s}niqture,prlor�o_Ifs issuance, also re- _ V_ �t i�'�. _,��.�, . .. t�`� < < �.. ! _ -_S'�\tiquire3theappflcvniloreucbpe�mllfo/ifod�slgRadsfo/o- � ` - ""�'�� ment�fhat he Ie Utensedpursuan}to fhe provlsions o(fhe {. �� .,,�,�,� t\\� \^��,:_` . 1.` n . � . . � � .� ..., Confracfor's:Ltcense�Lav�..(ChoPier�9�(commoncing wl�h � . � 1 � sions Code or,lhoi he Is exem f�Fe _ .. _ .__... _ � ., , :,,� ' " , ; � -__ __ __ " �� $ecf7on.7000f o/Division 3 0!�he Business and Pro/as- _ . - .; J � � .. � � .fle,. .A�.. � , r /rom arid 1he fiasis ' . �. . i �, . ; . .; . . . � , � . . � . . . , �'�i , ,, lor fhe-a ged exempfion. y y'ofa�ion of Secflon . - � --�1 --'-- �-.--- . .. ��_ . , . - -�-���--- •----- �'� ' �'I ` .,.��,,canf�oby any opplicont,/or o permit subjects lhe appli- --'-- --. -_ _ . � . - ... ... '� ---- �a civll,penolfy_of,nof moie;than{i�o�hvndrod �-------�----._—.- -----,7 - ---- --._. . � . � i dollars(3500J.: .. . ._ .. _. ��� '_ � . "Sea❑7044,Eusiness dpd Proless'ion} �II do the work,and --. _i- � • ---' �-.. w_ � .. ..,..�,. _�V I �., � ed for sala:-�.� ; � C .__ .__. . __ '. '_ '_._. . _ _ � ... Pr Y . � � i the sirDcWre is not intended or�offer . , . .. 'Code:'The Contrac- . ! . � � il'!:",1; � � � i . . , ,,.i��far'sLicenseL'awdoesnofoPP�Yloan,ownor.ofproperty ' �� - �_. _..'__._.�. ___ .._'. ___ . \•__.. .__ .. � f .�. .,;.wbo bullds on.(mproves�fhereon,,.apd.who�does.suth \., work hlmseH provlded ihat sucB ImprovomeMs are nof t_�'Y'�� - _ -�C�''� �� - ' � � \ Intended ol�o/fared(or sale.If;however;lhe 6uilding or � � - �Improvemont Is sold wifhln one year,of,completlona the � , � � � _ J _ - --- � � � - owner-buliderwtll have Ihe burden biproving Ihat ho did .� . -, � � . � J � �� nol bviJdor'improve fo'r lhe purposebf sala)� �� � \ �\� ,' -- - - ��'� 1'-'�� \�" � - -.❑I,osownero[tho poo�er�y,am exclusively,mn- . .. ! • � . �" �K�tracting wilh licensed contractors fo"con5lroct fhe prajecl -' . [-""..: ....'- ....-' ... ...-"--------- .�-.. ' ...�._` `. .. . (Sec.7M4)Buslne35tiad,Frole551005rode:7heConfrac- . � � � •- - fo�s License low does no�apply fo dn owner o1 property ;. i F�. : �.� � .. � � F'- - --� -- --- - -�-------�- - - - � �- - _ who builds or Im roves fhcreon,and who.conhacfi for � P i . _�.,_..__; ��'%'�� �'"�' '- such projecfs wifh a tonfrador(sJ,fitrnsed pursuont lo _ . __ - ..__ __ _ . .. _ _ ._ _._ � ` M�. . i,� � , i . . .._...... _ .... : _..---1hc�Conlratfor's!ltenseLow).. .."..� '�-. . � .. .o � s • :, ,: . . . . .. , � ,:_� . , .�'��_'._.___-..... _-_ _.-•- __ —. ._ . . .... ., .. ,. _ � ; . �.. , . _. __ . _...... .._ . __ _ _. . .� �� �, ',� �\� \�\, ...rr., i. � � . .. . . . ........ . .� . : � �— -- --- ._ _.._ _- ; - . ___ __ -- — - -- - � , � � � � � ' '' '� � � I am exempt undei Set:��� � ,. . _ , e J . . - . � ,. i .i, � _ „ . , .., � .., ., . . ; , . .� ._,. ��;'� , . �- ... '1 - �n:� I 8 8 P.C.for fhis ieason � ,. .. ... � � . .. / � ,'\_.�_ `-- - - �\ V . . Date ' . .� . . . . .. � _ • � -- - - __' , _ � . , . . . . .,,;. ,_.. . , . ,. , . ... .. ' . . i _..�_ .-�, _� ��� �,- �'� i y.� � Ownei . . , ,,;.,. � _. __. _. " . ` -----�.�_..-------_ . ..L1�i.� �>�,._. . .. � . -.. .,.... �� . , ,.., � , INSPECTOR'S NOTES -- -- ---�:� \�.`__'.� � - - � -:._ , � ✓�,,f, . . . -, i,�.__._...,.�,1 `?� �•,: I ... ,..,.. , . {—.____._. __ . _ . --- — ---------- --._._-------- �. .,. . ., — �.._ ..,._ ` .. , . __ .. ._ . _.- -__--__ - -. , ,-, c� c., . �_ ��� ,� � �:.: ' ----. .. ---_... . .__- ---- � . ` . � �:�: . , r� ... ;.� ,� � � � � ' _-.,. .. .�,., .,... .,. .,_... ..,�.,.1 ...- ,. ..... . ... ,�- .. ,� . � . . �.\-<�� _ �<-_ _ _s� _i t, � � �;: