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HomeMy WebLinkAbout1504A WORKERS-�oMPENSAT�oNOE��ARAr�oN - APPLICATION FOR PERMIT �� / I7J � I hereby a(f'rcm Ihat I have a ce�tifitate of tonsent to self insure,or a ce��iticaie of Workers'Compensation Insurance, ���� HEATING - VENTILATING - AIR CONDITIONING or aoI cerlif'ed cop y�hf reof(Sec.38 ,Lob.C.) � � y(/V�l./�I (,t KI 7 CE-818(REV.IOi81 j - � . Dolity f7o.' Com�an Y�� � Certified copy is hereby furnished. � COUNTY OF LOS ANGEIES 'BUILDING AND SAFETY �}'c3U�U �errified copy is filed with(he county building inspeo- FOR APPLICANT TO FILL IN BUUDiNG r�p �,� � A�„ �ion deportment . (PRINT OR 7YPE ONLY� aDDRE55 s"9 L� (/li�l" Dote/a`�G'y�APPlicank C -�' l /Q'/ IOCAU7Y � /J ��� � ` NO. TVGE OF APPIIANCE OR EQUIPMENT FEE "��n-t:>�•✓ CERTIFICATE OF EXEMP710N FROM WORKERS' NEnzesi ,.J COMPENSATION INSURANCE [RO5557. (�.G! , (This sacffon nwd not bo compl�frd�f fha work inrolved by ABSORPTION UNIT,BTU DiSiRiCE NO. VROCESSfO BY the permll Is for one hundrad dollars(f100)o�less.) I certify ihpt in the performonce of fhe work for which this 1+iR NANDIING UNIT,CFM � � J permif is issued,I shall not employ any person in any manner BOiLER,BTU so as�o become subjeU to Ihe Workeri Compensation Laws. nvvpovnt5 �AiE INSPECTOR'S SIGNATVRE Date APPlicanl COMPRESSOR,BTU ROUGH �,Q�r,�, � � NOTICE TO APPLICANT: If, after making fhis Certifica�e of VENTILATIONSYSTEM FINAL �� Exemption, you should become subjecl fo ihe Workers' Compensa�ion provisions of�he Lobor Code,you musl lorih- EVAPORATIVE COOLER VALIDATION with comply wilh such provisions or lhis permit shall be tleemB(/revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION � FLOOR BTU , I hereby af(i�m�hal I am licenzed under provisions of Chapler 9 HEATER: SUSPENDED UNIT�. '(commencing wilh Secfion 7000�of Division 3 of the Business wA« and Professions Code,ond m license is in foll Iorce and effecL • �"' y� � 3l 5 ► o Litense Number�� ��� lia Class ' ZU - V �'�� �� J� Lfe ContmcloSS�_��_�•�Date �O��G—F 7 � O H ❑ I om exempr u�der Sea ., ' uVi Plon check fee �1 5 Q 4 A °- B.BP.C.for this reason � PERMIT ISSUING FEE; �O 5 Q �$. . . . o�i � Dofe: 59na�ure 70TA1 FEE S I • •7 4,7� OWNER-BUILDER DECLARATION PLAN CHECK APPUCANT � 1 hereby affirm thai 1 om exempt from the Contractor's License ► � � �7�"�5� Low for Ihe iollowing reason[Section 7031.5,Business and NaME ProFessions Code): � ' �Q��—�7 ' ❑ I, as owner af fhe p�operty, or my employees with AODRESS • ages as iheir sole compensation,will do�he work and ��TY TEI.NO. � ihe s7ructure is not iniended or offered for sole(ScUion - 7044,Business and Professions Code). . . � OWNER �u� ❑ I,as owner af the properfy,am exclu5ively ton�rocting �` wirh licensed convoc�ors to construcl the project(Sec- qooRE55 tion 7044,Business and Pro(essions Code). CONSTRU[TION LENDING AGENCY CiT �✓TE�.NO. � - - I hereby�affirm Ihot ihe�e is a constru<tion lending ogency for , the performance of�he work for which�his permit is issoed �ONTRACTO ' ' (Sec.3097,Civ.C.). I � - -. � � nooRess ����� . � - ' Lender's Name CITY ��� TEL.NO. &'/� . , .. Lender's Address STATE l Cfu q/ LIC. ,o I certify thai I hove reod this oppl�ca+fon and s�afe thof Ihe ' �i�NSE NO. Iv/ //(O CtnSs C.�"� --�- � �-� � - above information is cvrrecf.I agree to comply wilh qll Coonfy. . ordinonces and Stote laws relating io 6uilding cons�rucfion, _ _. _ . ,_ _ _ and hereby authori:e representafives of fhis Counry fo en�er � pon+he obove-meniioned propeny for inspeUion pu�poses. SEE REVERSE FOR EXPLANATORY IANGUAGE . _ , . ..�- �.�d' /b-//—Sr 7 Signorure ol ApPliconl or Aq� Doie .. . .. . . .. . . . . . • � " • � � iN3fECTOR'S N07ES OWNER-6UILDER DECLARATION ` • _ ..1 he e6y�6ff � 1 1 . ., � ' irm i cl I an�emempt f om the Controc�or's ( � , •.. . . . _ . . l cense Law far.ih- fallo..�ing ason (Secl�on 703i 5, _._' .'__...... ._._... ..,....._._.._.._ __. _ __ . . ... . . .. ... ...�.._.. .. . _ .__ ... � � - �- BwlneszandPro�esslonsCode?�Anycityorcountywhich � � • - � ., � , � reqwres o permif to conslrud,eher,'ImproJe,demofish. i --- �� �----�- �� - � � - � � - - � � � � or repalr eny ehodure, pNor fo ils issuanre� also rr , 'i ���'". , � � , , ;�•'quires the cpplicant far such permihio/i!e'o efgned stafe- � --. �� - -� i - � - � ;-. � ' � men!thof he Is licensed pursuanf�o thc provisions of thc .'�.;. • ,_ , � CoNroUor's Ckrnse law(Ghopler,9(commencln�wlfb ��' � ' ��, " ;- ' . � , � "'-�- . _ _ � Section 7000)of Divisicn 3 0l�he Eusiness and Pro�es� � � � . sions Codc)or fhaf hels'exempt,fhereGom ond�he 6asi.c � , � � " � - for Ihe alfeged exemprion. Any viofolion of Sedion j__ __, _ ,_ _ _ , _. __ _ � � � � , 7031.5 by any opplironl,for a permi�subjecls fhe appfi- ; . � � � . . - - -- mN to a civif'pe�alty o(not moro fhon(ive hundred �... _ . . .._ _ .'_ . _ _. . . . _ . ___ . dolfcrs(5500J.: . ' � � ' - - - - � � ❑I,as owner of the property will do the wark,and ��- �� � � -�- �-� - , , �he-strucNre is noi in�ended or offered for sde. �.----- - - --- - � -� '�-- - - - � � � (Sec.7034,8usinessar.dProfessionsCode: TBoConfrac- . � � , . for's Llcense Lew does not oppfy to on owncr of properfy � - - " � � � who bullds or�improvcs fBereon, and who does such . . work himsef(provided Ihat such improvemen�s are no� � ' � - ' - intended or oHered7or sale.If,however,Ihe 6ulld�ng or � � _. _ _ . . . improvemenf Is sold within one year o(compleHon,the - - � � ownervbuilder wifl hevc�hc burdon of proving thot he did � . - � . �no�6u(fd or Improvo for fhc purpose o/safe.j ' � - '- ' -"� � ' `� •.�I,as owner af ihe preperS�,am exduslvely con- � � � � � � - �trccting'�vilh licensed�mnl.adors to mnstrua the prajcct � ,- (Sec.70d4)Business and Pralessior,,s Code�7he Confrao , ' �- �hor's Cicc�nsc Law does'not cppfy lo'on owner oI property - - - - who builds or Improvr.s ihcrcon,and who contracis for ., . � �. . � ' � � � such pro�eds wHfi a ronVvclor(s)licensed punuanf fo . � - � � - thc Contredcr's Litensc Lavi). � ' . . . �� , � .. .. . . .__.. . _ _._.. . .. . .. ._ _._ . .. . . ' -- I am cxempt undu Sec. ' '- i i'!I � 6&P.C.for�this rcason . -.�.- - , i .. � . . . . . � �. ' . Date � , ' �'- . . . . .. . .., ,' . , '�'. . . . . � � , � . , , , . .._._ . _ _ . Owner _ __ . . _ . , ,1i\ .. ... _ J�`.�� , .� _ .,r ' . INSPECTOR'S N07E5 � � � - � .-� � - - - .� - ..._ . . ,,.� , .� �� , - �- . � , �. . . _ . �. ' � -� .. . . . �. � - . � . �..�-�.s� ��, . . .' . . _.,C- _:- � . ...���