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HomeMy WebLinkAbout1508A (8) woRKeRs'connveNsarioNoecwannoN APP�ICATION FOR PERMIT LI37/� � I hereby affkm that I h4ve a certiticate of wnseN�o salf � _ , (nsure,or a cerlifimle of Workers'Compensation Insurance 76A36aC � COIJNTY OF L S AN E�STILATING '�A�R Ceul D'N�G AING r e d}'e copj'�hereof(Sec:38 ,Lab.C) ��_ele(Rev.-l0iat� - �� -� � T (� ; �Q�Y�Q�']�Iy Compan � .. . . . � J�1S Q �'� ' ' Certified copy is herehy Fumished.�� -���"���" " � � ND$AFETY �Certified copy is filed with�he county buildin9�^sP��- � � � - FOR APPL(CANT TO�IL�.IN �-- -��- - BUiIDiNG y / o/n departmrent. �� . (PRIM OR TYPE ONIY) ' ADDRE55 ( p,�� o(6�a{,. A—�� � � Date l�'��G�d 7 APPlicont � LOCntItY ���.n� J NO. TYPE OF APpLIANCE OR EQUIPMENT � fEE . � � � CERTIFICATE OF EXEMPTION FROM W KERS' ... NEAREST � ' �, � .� � COMPENSATION INSURANCE � . CROSS ST �, ' � (Thls s��tlon noed nof b�iomplitod if ih�work Involved by-- ABSORPTiON UNI7,BTU oi5taicr r�p. - vap�g5to Bv . Iha parm�t is for one hundred dollars(5100)or less.) q�R HANDLING UNIT,CFM �' � ' 1 certify ihat in ihe performance o(the work for which fhis - � � , ' ,permit Is issued,�l shall no�employ any person innny manner gOnER.BTU � to as to betome su6jett l0 1he�Workers'Compensolion Lows. novRovAis DAiE INSOEROR'S SIGNAIDNE � ,- � ' COMPRESSOR,BTU ROUGH � Oate . . . aPPlicoN - . . . , ' NOTIGE TO APPLICANT: If,after making this Certifica7e of VENTnATION SYSTEM - FiNal '��'p6 I.�,`�, � � � Exemption, you should 6ecome su6ject ro the Workeri. � � � Compensotion provisions oi the Yabol Code,yoU�musf forih- EVAPORATIVE COOLER ! VALIDATION � � with comply'with such�provislons or this permit shall be � � � 'deemed revoked.- � � ���� �. . .�� � � � FURNACE: �� FAU RAVIN �- � - ' �' � � � ' LICENSED CONTRACiDRS DECLARATION��. � FtOOR BTU� U �� � � '1 hereby affirm that I am licensed unde�provis�ons of Chopter9 � HEATER: SU57ENDED -UNiT -� � -"" I � ' �i . '(commencing with Section 7000)of Division 3 of the Business �/ WA« . _ 3_ � j ' � ', ond Professions Code,apnd my license is in(uil force and etfecL�� � � ' � -�-�- , a ' �. �.Licerise Number��/ �/� lic.Class�e"Z v . � . . - . . . . . . ..' �- -... � � . �, � V . Conlrac16L1��� Oote �O�r[G'-'�7 j O ❑ -. s , r- '. � I om ezempt under Sec �� ' � _ . . _ _ . .. __ _._ � . �1 5 Q�F � ��. - Plan cHeck fee �. . . . .g N B.BP.C.for this reason�� /� �U � ? ` _ PERMIT-ISSUING FEE S � � . .7 4.7 S Date: TOTAL FEE 7� 7S � � �Si nmure • 9 . . .7Q75� � - OWNER-BUIIDER DECLARATION- -- PWN CHECK wapuCnNi � . - , � . � .I hereby affirm thal I om exempt trom the Contractor's License�� . . ► I . . �Q C� —8 7 . � Low for fhe following ieason(SeUion 7031.5,Business and � NAME � - . � . . Professions Code): ' -� � �� �� ��- ' �� ❑ I, as owne�.ot Ihe praperty, or my empioyees wilh � ADDRE55 � i � � �wages as Iheir sole mmpenwtion,will do 16e work ond-- : � � i ! ' � �. . the structure is not imended or offered for sale(Sedion ciTY ie�.NO. . ., ; �. � 7044,Bosiness and Professions Code). . .. ... ...... . �17 . ._.. .� -. .� --- � � ' � . '. OWNER 7w ; . O �tion 7044eBusinh ss ond Frofe sionslCode)P`on'ra(''n AD�RE55� � C�� � P P Y, Y 9 . __ . _ _ � with licensed contractors to consiruct the ro"ect Sec- � � � ' CONSTRUCiION IENDING AGENCY �� -�--� aTv e � � ���� �����-�tEi.�n70. '" " ' � �'�� ' � � ' I hereby affirm�hm there is a construction lending agency for - ' ' the performance of the work for which Ihis permif is issued -� �pMRq A{ � ����- �---�h � �� -�----��-� . ► I� .- . � (Sec.3097.Civ.C.). . . T� /-� �l . . CITY JI [e/�' ..7EL.NO�C . ._ : .. ; _ .. ._ . ._ . ..,.._.. . � lender's Name � . � ... .. .f7� .. . -/70 �_._._ . . __.1 _..`_ ._' ' . _._:__.. _.... __ ._ Lender's Address � � � � A�D`� . . ' . i . y ,. . .. .. . ... ' STATE / UC. ��/� ..__'� I certify ihat I have reod ihis opplitolion and stale that lhe . LICENSENO. (,a .- -- ..CLASS. (�" � —.. ..._.. ,.___. .. ......._.. .___ ....._._:_._.. ....... ._�._._ ' above information is mrrect.I agree to[omply with oll Caunly . . . � � � � � .ordinonces and Staie laws reloting to building conzlrvction, ,_ ,� „, , . , ,_,._ __ _ , _._ � and hereby aulhorize represeMotives of Ihis Counfy lo enler � - �,� �� --�� . � -�� �-���- � � - ��� ���-'� � -� . upon the above-mentioned prapery for inspectian purposes. � i ' . .. _. .. ._. .LANGUAGE._- . -- - ' .. __._._. . _.. . ..� .. _.. ..,. . .. .. . ._ . SEE REVERSE FOR fXPLANATORY . . ._ � /o—/L—�7 • � � S�gnoNre of Applkan�oc Agem .Dare � .. . . . ........ .. .. .. . . . .- .... - . .. ..,,i . . -� � � . . r:. -... r r _ � S . � . ., . .... ..f. � . , ., c�4 f ..,,..�, .. . �� ... �. . " � " ry- "' ' -� - IN3PECiOR'S NOTES O4VNER GUILDER DECLARATION ,.' . � pe ` I \' _ \ � �� ��i .. �' �-=1.fi reby`aff'rmQhat I om�exempLfrom th Contr.pctari � � � �'"A� ��'"�' � �.� ��` License Law.forifhe following reasan�(Secfion 7037.5, . �._ . _�-��.�.._�__.� _.... .._,.._. ._. __.__�.��__�__._ ...�.__.' ' 8usl .' '"' :.",'" � " � ness and Protoss on CodeJ.Any dfy a counry whfch � ll Ii . r , . , _ - ' , _ . ... ` ,y,:=)�•. ,\ ;,�. ``� '�1� �.:•3 _,', .,_ `"" � : �'reqWros�a permD lo construc�,pllcr,7mprove,domalish, t - - '--- --��1 --; ' �� ' ' ' or ropalr.,any sirutlure, prlor fo�lfs�7ssuance, otso io- �r ',� �.��,.. ��..5'����-- _�i 1�' ? '.:. .,�... :.,. � � ,.I - ,''��\qWresfhoopplimntiorsuchpe�ml�foYifedslgnedsfofe. . �- `.� � � '� 1 ' 1�. -� i ,._ ' � ' �' ' � � � � ' men/�IBaf 6e fa l�rensedpursuan�lo eha provls(ons af Ihc . �..?._:.��;� 1\� �l�,t��j � �.^,,; L . ., , , . .Contracfors�tkens la� (ChopJer9�(commencingwith y �" ��--- - i�='�' -:�- �� ` t ,Se[tlon 7000J�of,D Islo 3 0l fhe.Bus/ness and.Gro/es� I . .• .�. r. � ._ ... . . .. . . - ;� �,� ;� � ; . ' '�sibna Cade or 1hc�h ! -xempl fherelrom ond Iho 6osls j � .. �,' � '-'-.--� - ---�' ' � • ,.. .for tha afloged exempflon.�Any-vlolatlon o�Sectlon � �.- T '-: .. _..._'_._ ._.L. ._ _ ,.:.":_ . .__." � i . . , 703C5 by.a'ny dpplicanf for.�v permlt'subjects fhe appli- I �.. .�. . . ,.... .,..; . ., � � �.-.--'-.-_-._._ .__�_._.._ _ . .�.. �� , �, ; , ,.,canf to a clvll penolty_ol nal.more�.lhon five hundred �. � �. . - � �. _, . .. -- i i �� dollars(E500): . . . l_ . .._ ' _� _ � ___ �� ` �._-.-. --"�-� .--�-'--". '� ` �I cs owner o(,fhe ropert will do Ih work.ond . i I T . � ;,r., . . � � ,_ , �-the slrud re :naf intended or�offered for sale . L.-- --- - :. . .i_ . .____ _ _._ +-,--._1. i_ _- - � ,�.� , .�.:.,.(Ser.7044,Bus(nessandProlesslonsCodec��.TheCori�rac- ',-'- - �;V � � ,. .� -. t :. _.,tor'stlrnnselowdaesnoi�applytoonownerofproperty . � ' I � � � ' ._' � il; who 6Wlds�onlm roves,thereon, ond who does,.such . � s__--�• -� -�------ - ----,.. __.._...---.. ._. _ _ • P � work hlmsefl provlded tha�such 7mprovemen�s�.orc no� . . �'\ 1!�..�� ti�._S�.'�:Li A �i'�-__�. . .. , . �� __ �. \ lntended o�dlered/or aale.Il,howover,.the bWlding or ;� 1. . . .... .. . . i � ,--'- .�...--�-----.�. �.: . _,.,-_ , �;,..;:.improvement.is sofd wNhln one yvar oI complet/on:�he ' �--.--i-..-.-. _ __�-__ -.:-__:_ -.:'..,. .. [....._."�. ���- ownerrvbWlderwillhovafhe6urdenolprovingtfiafhedid ' � � _f L� �.��,-`,; � ` � �nof bulfd or Improve for}he purpose o/sole.)���'�°�� ' � __ . .��J-L\_�1 .)'�'. `C. �. _ �. , , ..� ...-. �..". -.- ' ,C" -"::�Q I,as owner of�heprQperly,am ezclusivdy con- . , *�. ��; � � ' i y I ' - - Iracfing with li[ensed te�rotton�to convruct the projet� : "'_. _..'. :___ ____. " _'___. __._____ � . .- Sec 7044 Busln s' � f � C.d.. ifi C r . - - - J es ond Pro ess�ons o a e on rac- ��l�- �,i: ��.�:. � . ! I � - � �fo'r's licenso Law does rio)apply fo'dn awner ol prope�ty ' � � .__. .._'.'-.__..__ .__. _.__. ___ � � �---� -��- --� who bullds or Im roves fhereon,and who confrocfs lor� �� � " • • " '� :;_._. � � �"�-"� � suefi projeds w7 h a cont�acfor(s)hcensed pursuvn�lo � __ ... _..._ . .__. ., ��� •, -. .. •.-.. . . ...�_. . '-'-�ihc Contrador's Lfcensc f.owJ.':'' , � . � '\.11 � • • � - � .. ., _ . ," .. , , . . �_ .__ . .__ _ ' '_ _ _._ ......___...__ , . , - , ___ ._ ._.. _. . ���. . _ ,. _ . t'!C i\,.��.. ._,.. -._ -.. . ....__...._ , . . a � r �-� . ;.. . . . _.___.__ .._. .__.._ ._._..._-____ � ... ____..._ _ _. . . . � `� _ ' w�� ' ,{ ' � .,.. . �. . . � � I am exempt-under SeC�„� . . •._'- . . . �..,, .. . � �6&P.0 for this reason- � �� �, . . ...,. - , � , . . ,...�,.. �; �_ . :. . ._. .. , �. � �- � , . - � . .. �r� . - � , . .. ... .. . ._. i ,�]vc'��.�1 1� _�J� ,i -- -i Date �. , - .. . �_ � ,,. �, � � ._,- � , �., .., ,i, �r,r„ ... ... . j_..___._._e-- ..;',�,. � _�J ...:_�.,z�i..r 1�.��-�.�. _'_� � Owner ... � ��.�,... , , , . ` '..., �.. �;'`.... .. .. . . , ' . . j � ,: i� �...�. � : ,. _ ,,.,.� ,�i�r,� � � , ' ._'_' .._— ____ _� . _ ._ � . ��__. . . , . . c � - 1 " _ . . . . .�e���.i�.� i��,..�,.�. �� . .. .�U ��� J J...r-� ( ... .. ,,.,; .. INSPECTOR$NOTES f -� ,\ '-- ' - � � �� . , _ . _.._ .--.-i . . . ¢ _�', __ ,.� � f , -_, .„ � C ,__ _ `_ ------- - - _ _ _ � .. , @ , . � f . _�, �._ ,, ._ _ ____ ___ _ _- _ - - - �� � � , � � .,J1h . . ..� � . . _.� �___l� ���_ ��.,,�� ��r ���� . . . `� ,. _ .. , . Cl.. ��'.