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HomeMy WebLinkAbout1506A Y....,...�n, wrvirtNSATION DECLARATION APPUCA?ION FOR PERMIT y?,7!g � 1 hereb aff'mm thar I have a certificate of consem ro self �nsure,o.a ce���ficate of Workeri compensm�on Insurance,- �bA3eac HEAT�NG - VENTILATING - AIR CONDITIONING ��o agj u ied cgpy t reof(Sec.38 ,laAb. )/ CE-818(REV,10/01) �' �� Z�G���'/11�� Compon�' �'• µ . . . .. Certified copy�s hereby furnished. COUNTY OF LO$ANGELES BUILDING AND SAFET �p rified capy is filed with the counry 6uilding inspec- � FOR APPLICANT TO Flll IN BuimwG fion doportmenl. (GRiN'f OR 1YPE ONLY) � ADDRE55 ' Da�e �U IG"�7 APP��can� IOCALITY � ' �� �1 NO. 7YPE OF APPLIANCE OR EOUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WO KERS' NEaRE51 COMPENSATION INSURANCE � � CRO5557, �� (This a�Nlon naod nof ba complated if 1ha work involved by ABSORPTION UN17,BTU D�SiF�Ci NO. . . PROCFSSED BY � tM permif is fot ono hu�dred dallon(S100J�r IYis.J � q�R HANDUNG UNIT,CFM ��� I cenify�hat in ihe performonte of ihe wark ior which this L, � �permii is issued,1 shail not employ ony person in ony monner BOiLER,BTU so os to 6emme subject to the Workers'COmP¢rli�ti0�LawS. ApPROYALS DA�E INSFEROR'S S�GNATURE Dole eppijcanf ' COM7RESSOR,B7U � ROUGH � .� NOTICE TO APPLICANT: IF, af�er moking Ihis Certifitote of yEN7itA710N SYSTEM F�P1AL [��j'�7 Exempiion, you should become subject to ihe Workers' Compensa+ion provisions of the Lobor Code,you mosl forth• EyqppgAilVE COOLER VAIIDATION with comply with suth provisions or this permit sholl 6e . deamedfevoked. / FURNACE: �FAU GRAVItY JU �� . LICENSED CONiRACiORS DECLARATION FIOOR - BTU ' I hereby a4firm fhat 1 om litensed under provisions of Chopler 9 SUSPENDED UNIT_ ' �(mmmentinq wilh Section 7000J 6f�ivision 3 of the Business HEAiER: WA�� and Professions Code,pnd my license is in full force and effect - � � � . � �6�vyG �'7�� 3 S � � Litense Nomber lic.Class� - ► � . y ��, -y^�7�_ �- �` ..} � / r-7 � a ConrmcroF��T��Date ��"�V�d / �� . � 0 � U i I am exempt un�e�Sec. r�5 p b}� W Picn check fee a B.BP.C.for rh�s reoso� PERMIT ISSUING FEE S I �' • • • •S Z Dole: 5gnature � TOTAL PEE 7Y J � ' '7�7� . OWNER�BUIIDER DECLARATION PU+N CHECK APP�ICAN7 ' •• •']�.'�5 v 1 hereby offirm thot 1 am exempt from the Controctor's License . , � Law for the following reoson(Seuion 703I.5,Business�ond NAME ' �Q'Z t—8`l Professlons Code): ❑ �, as owner o(Ihe property, or my employees with ADDRE55 " woges as iheir sole compensation,wiil da the work ond- � . ihe strutNre is not intended or offered far sale(Settion CITY .TEL.NO. � � 704d,Business and Prafessions Code). fr - _ OVJNER ��� � ❑ I,as owner of the properry.om exdosiveiy controcring , wi�h licensed coniracrors to construct the projeu(Sec- ��� � - tion 7044,Business and Professions Code). A�DRESS C�„ � CONSTRUCTION IENDING AGENCY . � CRY � tEL . � � I hereby affirm fhat rbere Is n construciion lendinq ogency for . ihe performance ot the work far wbich ihis permit is issued - CONTRACfO�� � ' jQ-j � ` �� (Sec.3097.Civ.C.J. . . . _ . -. ' . A�DRE55 3 �� ��Q - . . ' _ � _ . lender's Name � � CITYp� �� TEL.NO. 9��/�, . '. .. . lender's Address . STATE /p q LIC. . . I cenify�hof 1 hove read ihis application o�d s�a�e Ihat fhe UCENSE NO. (�/ / CLA55 - -.- - . .. obove informa�ion is correcL 1 agree�o comply with all Gounfy ordinontes and S�are lows relating to build�ng construuion, . " ' ond hereby authorize represenratives of this County io enter . � ' � . - upon fhe abo�e-ment�oned propeny ior inspection purpases. . SEE RfVERSE FOR EXPLANATORY LANGUAGF /G-/G--�i7 'ignaNre ol Applicon�or Agent Da�e � � �� - - � � ��- �- ' - � -.t • • - ' ' ' • IN71'tC70R'S NOTEs OWNEF:-fiUiCDER bECV,RATION . _, � � . '� ,: ., _ ,��.. ,. _ _ � -'�1 hereby offirm d�ci 1 om exempt irom thc Controctori ��-..�.� - � License Low for Ihe followin� reeaon�(Section )03I.5. '„�.. .:�`� ., .,�'.`..-�,�.,�',i`, ... ._. .. . .. . . ..... .. .. _. _ - . , .-- - � usinessendProfeizionsCode) Anycityorcoumywh�ch � - -- � . . ,-�- • -� - , - � Bequires opermit ro corrsfruct,alter,Imprave,demolish. - - - - - � - - . �"" - - � � or ropolr ony struclure,prior�]o 1ts issuanrq also re� "�t ,:._, _ _ ` � � ...;; �.'.\qufrosfheappliconHorsucbpermlifo(ileosignedsiafe- , -----�� `� ' . ' menf Ihaf ha is licensed pursucM ro fhe provisbns of�he ��, , � Conlro<lor's License low(CFapfer 9{commencing wilh ' ' � " '- �"" � � � � .� ' . - � � Sectian 7000)af Division 3 a7 1h�e Busrness and Pro�es- � . ; � . � ' sions'Code)or Ifiaf he fs exr.mpt fhcrclrom ond�fie b�as�s , , � �� � for Ihe allee�ed�exemprion. Any violclion of Seeffon '_.._ __ _ .._. ___ . , , � . 703I:5 by ony oppiicvnt for a permit su6jetls fhe appli- ' . .. , . . - cant to a Uvil penolty of not morc�han live hundred ...--- - _. . - - ., . . . . . dolfars(S500J.: ;� � ' ' �-- � ❑1,es owner of�ho preporry will do the wo�k,c�nd -�� �� -� � � � -� .--� � - -ihe s�ruciwe is no�iNended or offered for sole: � '-- . ------- �.� -- . - - - � -� .- �� � (Sec.704a,BusinessundFrofesslonsCode: TfieConfrac- � ' , , , , for's LRense Law docs noh apply fo an awner of properry _, . . -�� --- ,., � � � , . �wfio buifds or improves Ihcreon. and who does such , _ � _ . wark himsel(providrd Ihaf sueh improvemenis ore nof �- '��` � � intend�d or offnred for safe.If,hewever,ihe buildrng or ' � ._ . . � . - improvemeM is sold wd�hin one yoor ol complefJon.�he � - - . ownervboilder wli!have Ihe 6prden of proving Iho�ho did . , , � . '" not buf(dbr fmprovc for fhr purposo of sale.) � . � ' - ' ' " ' ' .O I,o:owner of the propCriy,om ezclusively com � � . , ' - troc�ing wiih lite^.sed�coNr�eMrs tdcon;huct ihe preject � • ' � ' ISec 704d}Buslness aryl Pro(cssiohs CodP�ihe Con:rcc�. . � ' ' - -for'z License Cow doce noh oppfjrfo on oviner of property ' ,, � , ,: � who butlds or Improvc.ihcredn,cnd who conlracts(or � � � - � � . such projecfs w7th a mnfreclar(s)Ircensed pursnaN�o . > + , '. . . . _ . . . _. rhe eonrrodor's[;cense[owJ. � � ' . , . . � . .. . , . . ._ _ . ' _ __.. _. .. . ___. , . , . , ^ ' � _. . . � - ��--� � � ..I am ezempt under Sec.. . .. ' _ r::! 1 � � � ' . � B&P.C.f6r ihis reason . � - � Date .� � . � � . � .. .. . . . � . , � . . . . ' . _ . .' .- ,- . , � - � . . Owncr .. � .. .. �. , .\ .. .� . . . . . . , ,. � . . . . . .. INSPEC70R'S NOTES � - - - -� � - - � � - ,�: ?_.: f '