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HomeMy WebLinkAbout1505A (8) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERM�T � I here6y affKm ihat I have o certificare of consent to self � L�3 7�� insure,or a certificate of Warkers'Compensa�ion Insvrance, HEATING - VENTILATING - AIR CONDITIONING ceri�fied cop ihereof(Sec.38 ,lab C. 76n96aC . Q//�,/a,.�� y�//j /� t� CE-818�REV.10/91) . . . �ary � Compon �`• Cenified copy�s hereby fur�rshed. COUNTY OF LOS ANGELES BUILDIMG AND SAPETY 3 U�v Certified topy is filed with the counry 6vilding intpeo- FOR APPLICANT TO FILL IN - BUR�iNG �����r�,p ���L ��� tion departmc�ent. � �{— �PRIM OR TYPE ONLY) NDDRE55 � LZ,(,�i` Date ���1'ra� APPlicanl-��'`'�%" • � . LOCnL�Tv(n � G� NO. TY7E OF APPUANCE OR E�UIPMENT FEE �r CERTIFICATE OF EKEMPTION FROM W RKERS' NEnRESi COMPENSATION INSURANCE CROSS ST. � � � (Thit aoctlon noad no1 ba compial�d ff tM work tavolved by Ag502PTION UNIT,BTU OiSTGiQ NO. PRp�ESSED BY � Iha pormit ts for ono hundrvd dollars{;100)or Iv�s.) � � � � I certify thot in the performance of the work for which this A�R HANDLING UNIT,CFM permit is issued,I shall not employ any person in ony monner gp��ER,BTU so os to become subject io ihe Workeri Compensalion Laws.. . nopppvpts DATE INS>ECIOR'S$IGNATURE Date- AppliGanl COMP2ESSOR,BTU ROUGH �� �� NOTICE TO APPUCANT: if,afler making Ihis Cerlifitafe of VENTILATION SvSTEM FINAL � � Exempfion, you should become svbject to ihe Worken' - Compenmtion provisions af the Labor Code,you mu;�forth- EVAPORATiVE COOiER VALIDQTION , � with comply with suth provisions or this permit shall be � deemedrevoked � / FURNACF. FAU__GRAVITY � LICENSED CONTRACTORS LIECLARATION FLOOR BTU U �O I herehy affirm Ihat I am licensed under provisions of Chopter9 HEATER: SUSPENDED UNiT_ � - � '(tommendng with Section 7000)of Division 3 of the Business �''�A« and Professions Code,and my litense is in full iorce ond effect. �j ' � �J O c C� �� License Number�G I�/ C" 'lic Glass���U , V --�/�- C � Conlracl �« � +Date �n'-��`d 7 � � , � i ❑ i am exempt under Sea . . .. . ��,�j�.Fj A . V Plan check fee °� N 6.8P.C.far ihis reoson� � �r.� � , � �� . z PERM17 ISSUING FEE S Jp '� Dafe: Sgnot�re TOTAL FEE 7�f , � • •7 Q],5 OWNER-BUILbER DECLARATION PLP.N CHECK APPUCAN7 � � � . �'](�']5� I hereby aEfirm thot I am eaempt from the Contractor'a license . ► � law for�he following reason(Setlion 7031.5,Business and NAME . �Q`��-�7 Professions Code): ❑ I, os owner of fhe property, or my employees with ADDRE55 � - wages as their sole compensation,will do the work ond ��T� 7EL Na. � � � the strutl�re is not intended or offered for sate(Sec�ian , 7044,Bosiness and Professions Code). OWNER ❑ I,as owner of the properry,om ezdusively contracting MAIL �q- with licensed conlraUors to cons�rucl the projecl(Se[- qDDRF55 iX[1 �✓ tion 7044.Business and Prafessions COde). CONSTRUC710N LENDING AGENCY CIT �TEL.N . � �"� - � 1 hereby affirm Ihaf there is a construc�ion Iending ogency for � Ihe performance of Ihe work for which this permit is Iswod� CONiRACTOa . ' �� �> . , (Sec.3097.Civ.C.). � , � � - . � , � - � � A��RE55�� �• �� - . - . lender's Name p cin .�J rei.No. l`�� �i�ZJ Lender's Address SiaiE Gy(� / �UC. y ' 1 certify fhof I hpve read this application and stqte fhat the UCENSE NO. / ( �l� CLASS C.."�� � � ���� � � - � above informotion is correct.I ogree b compty with oil Coumy ordinantes and S�ate tows relating to building construction, � , � _ . _ . , . . , ._ � and hereby authorize represeNaiives of ihis County to enler upon the a6ove-mentioned property for inspeftion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE. � . .. - . . G+�-f��-•--� /0-//-�7 SignoWre o!Applitanl or Agenl �ale . - . . - . . -.. . • .. . .. . ° - � � -� - � INS�ECTOR'S NOTES i OWNEF;-ESUILDER DECLARATION � � ._ -... .. - . ,::- � ....�, . . . ..7�"' �I'hereby afflrm���ha�I am.exempi frdm the Connacfor's � ' � ��� � �� ' '- � • �� Liccnsc Law fo� tbo fc��owing reason (Secfion I071.5, � . ._"_. '_.:_._._.___.....__._........_....__.. ....._' .. . ._ . . ... . __. _. . .. . _.. . Business ond Prolesslonx Code�:Any ciry or couNy which � - � � rcqulres o permil�fo cons��ucl,oller,Improve,demolish. . -��-� � - � - - � -� � � - - or repair ony struUure, prio��lo]Is lssvonce, clso re- � ' :.'� ', - , , ; .. _ ''�qu/res Ihe applimn�lorsuc6 permli'lo R1c o sl�nedsfale- -- - - � ' ' - � - � � � menl fBct he�s ficensedpursueN fo tFe p�ovis�ons of�he �� .•� �'�`� '4 ' [o�rrocro�'s Li<�nse Low(Chopler 9(commencing wfth �-��' ��- , �-, - . '� -- ,�,� " �- _ _ ' SecUon 7U00)01 Division�3 0l�he Business,and Prolrs- \ �s�on's�CodrJ or Ihat he ts exempl fherekom and fhe bosis I � �, ' " " . � ' . !or �he olleged exemp�ion. Any Nofalion o/�Section . � ' � '� � , 7031.5 by any appiicant for v permil subjeUs Ihe oppli- .. . _.�. ... __ _ _ , . , . . � , . . ' tant fo a.Uvil penoqy of no�mo�e thon live hundrod _._ .... _ _.__ .. . .._. ._._. dollors(5500).: � �� � - . . - . � []I,as owner of rh-prapeny will do the work,and �� . ihe strucb�re is not intended�or.ofiered for sole. .._ . . . . __ .. . . .. . __ ___ � �Sec.70J4,Evsiness end Prolesslons Code: ihe CoNrac� , , - . .for's Llcense Low docs not epply la an ownsr ol proprrty , - � � � - � , �,. - who builds or improves thcreon. and who dons soch , . work himself pravided fhal such Improvemenis are no� . ' � ' � • iniendcd or offcred lor sole.IL however,Ihe boilding o� � , . , improvemenf!s sold wi�fiin one yeor o!mmpletion.fhe � � �� � owncr-builderwilfhcveiheburdeno�provingtho�hadid � . . � nol build or Jmprovc for Ihc purposn ol sole.J � � - � ' - �' ' -t , ' � � , � .�I,cs owner af Ihe property,am eedusively mn� ' . � � ,, , � � trecting with licen¢ed coirrro<tere�te mnstrucr iFs projec' . ' _ (Sec.7044)6�slnoss chd PrPlesslons Code�The Conlroc� � . �or's l+cense!aw docs iro!opply to"on owner ol proper7y � ; r . - who builds or Impraves tF.erean,cnd who conlraUs ior � . - ' ' � • such projecls wHh a conhoclor(sJ licensed pursuaN b � ,� , „ a - - � !hc Conlracfor's Llcensc Cow). , M � { .. ' �. ' ., , - . . . . . _. . ,. . . e � � � � I om exemp�under Sec. — i �.,' I , , B&P.C.for Ihis reoson .__. _..._ . . ._-- - . ... .. . . Datc . . , . � �, _i' � , . . � �- - � —- � � � � '.!. (+ . . - �Owner . - ,. ,�\,'.�, � .. \ • . .. .. . , INSPECiOR'S NOTES � � �� � � � . . _.1.;' ' , ..� . . . . � . � �.� . . . . ... .:. ....,�.. . ... ,