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HomeMy WebLinkAbout1509A � . - � �� WORKERs�oMPENSAT�oN oE��ARAT�oN � -� � APPLICATION FOR �PERMIT � � ; ' I hereby affirm that I have a certificate of consent�o self . r2. y�7 I� insore,or o cert ficate of Workeri Campensatian i�s��o��e, . ���� - -��HEATING�-�VENTIIATiNG - AIR CONDITIONING -Q r o�p�e7r-tified 5opy.th�eJ eof(Sec.38 ,lab� .) '� �'��� � � � 1�/l/S�"/�".�'Y3�I% P . . •.� .-CE-818IREV 10/81)�:. .. _ `.. . . . . .... . _ . __.. , , . � . Polf<`1�ro. Com an Certitied topy is hereby furnished. � COUNTY OF LO$ANGELES-- ---- BUILDING AND SAFETY��� �U Certified copy is filed w�th ihe counry building insper -pOR APPLICANT TO FILL IN qDoaE55 �r�3 G'(h,f � -f tion depa/rfineM. p � (PRW7 OR TYPE ONLYJ ' � ' Da�e�a-'�rr"�/APPlicon4-� /� � IOCAlI7Y �. . � �,� . NO. TYPE OF AFPLIANCE OR EQUIPMENT � � � FEE - � CERTIFICATE OF EXEMPTION FROM W RKERS' � --� NEAREST � '� � �� --- COMPENSATION WSURANCE' � � . CttOS55i. ,�,r,t �. , �TIIIf NC1IOt1119@fI ItOI bB COrt1PI91�(I I(1IIY WOfI(IIIVOIV9d LY�� ABSORPIION UNIT,BTU OIS�FiCT NO. . � PROCESSED 8V . fhe permll Is for ona hundr�d dollars(S1D0)or IsssJ q�R HANDLING UNIT,CFM � � � - I cerlify thol fn ihe performance of the work for whith�his � � ' permit is issued,I shall not employ any pe�son in any manner gp��ER,BTU - �so as�o become subject to the Workers'Compeniation Laws. ., AvpROVa�S DATE INSPE[TOR'S SIGNATIIRE . . ..Date eppli[ant . , . . COMPRESSOR.8TU ROUGH ''� `l�� i NOTICE TO APPLICANT:.If, after making lhis CeHificate of � VEN7ItATION SYSTEM � ' FINAL � '�j � �� � ��Exemp�ion,�yod should 6ecome sobject to�the Workers' ' � 'Compensation provisions of 1he Lobor Code;�you"must forih- EvnroeAnVE CootER ' VALIDATION - � ' wiih comply with such.provisions or tMis permi�shall be � . ' deemed revoked. � �, -. '�-' � ' - -�� FURNACE: FAU RAVITY�-� - ���- � - ��� � � �. � �UCENSED CONTRACTORS DECLARATION � Fi00R eiU ' , � I hereby aHirm fhof I am licensed under provisions of Chapler 9 HEAiER: SU57ENDED � UNI7_' � � � �� � �� �-�(commencing with Section 7000)of�Division 3 of the Business ' �'A« ' ' and Professions Code,and my license is in full force and eHect.'" "- " � '�' �'. "�-��' "�- � � "�� � } '' . . �o '.J-� ZS" 0. �. � License Nu� er ae yy � ����.��a55 C���iv..... ._ , . . . .. , �.� ' V . -" m Contracro� . ��G Dare �U'��b"d � - _ _ . _ ; O : ❑ I am ezempt un er Sec. ! - �1 5 Q 9 A � : W Plan check fee � °, $�: . . . e Fj w B.BP.C.for this reason , _ _ .. _ - PERMIT ISSUING FEE S' /Q ' �Z Date: � • •�]Q`]5 Stgnarure TOTAL FEE j rf � � OWNER-BUILDER DEGLARATION� - � � PU4N CHECK A7PUCANT " � � • ' ��7 G.7 5�_-' . � � I hereby affirm thal I am ezempl from the Comroctor's License� � , I, � . Law for the ioliowing reoson(Seclion 7031.5,Business ond NAME � " .. �. ' I ' � Q 2��8 7 . Professions Code): � � . ' � � ' - . -�'� , , �. . . �. ❑ I, os owner of the property, or my employees witb A�oREu . ' � �� �- wages os lheir Sole compensalion,will do Ihe work and' GTY � . TEL NO. � the strocture is not In�ended or offered for sale(SeUion � . � , . . � 7044.Business and Professtons Code). . . -' ' � - � - �� ' - �� '� � . . . . . - OWNER ' � � ' . ❑ I,as owner Of 1he pioperty,am e:dusively mnlra[ting �IL � , - � �. with licensed coNractors to consvuc�the project(Sec--� / �� i� -� , � �� �-� �ion 7044,Business and Professions Cade). ��� /DDRESS 1 � � C .,�� ' ' � � ' � ' CQNSTRUCTION LENDING AGENCY �� � CIN �,��'�- iEc"N . - � "-- - �' ��, . � � I hereby offirm that Ihere is a ronstruction lending ogency for �� Ihe performance of the work for which Ihis permit is issued— �- �pNTRACT '- ----�"'�J-/�-` � - �"" , _ � ' (Sec.3097.Civ.C.). �. . -... - .-.- — _ ._-.. _ ._.. ._ . . �p /' . •. ..�- � . �. . .. ADORE55 d I N/'. ... .�l� : .. . ... _. _-.�.� . ��.:-. . .. . .... ,_ - .... � . Lender's Nama � p . ! �� �, � � . . .. , CITY��,,,�-���.,,�� . ._. ......7EL.NO. /.� G�CJ '._ ' ___ __. ._ . _..._ .._.__._ .._ _. -. Lender's Address ¢/' �o . � . ' I certify�hat I have read this-opplita�ion and s�are tha�the--. iiCENSE NO. , /�(p -�--•-CLA55- c� �-Z. - - � , .� .._. .... ___._ .. ' _._.._ . . ._. .._ _. ._ _.,— __. above information is correU.'1 ogree to comply wilh all County '�. - ', � ordindnces and State laws relaling lo boilding conslruction, � . ._ _. , '� _ � ' , _ � . and hereby aothorize represemarives of this County to enter � �� � �� --� . . ��- ��� � ���� -�- �-� ��� �- ' � ��� � -� upon the obove-memioned property for inspection porposes. _ : SEE REVERSE FOR EXPLANATORY LANGLJAGE. _._. ' ��-�-�-�-----� /a-'�c�7 _ -- .- - �__. . . __ _.._ - ignonre of Ap0licom or A9 .... .� .. .. --... - ... _. _.... .._. . . ent Date . . -..-. ..�.. _ l d , v..V� ..�. u � . -. l f .. �.� . . . .. . .. r ,� ' ...� . �� _ . . . - ` r :�: �"I� :: �';' _ ' . ,'. - � WS�ECTOR�S NOTES ' �bWN�R-BUILDER DECCARATION . , ;•_ _. r �ty �\:.�� � i � ( � ," . . �...... ..,._...,,...�,..,., ' . . � 5=�' ='�I�ha eby afflim t at I am exempt..from the Coniractor's � -� � �v� \'7....�.:.C.,i...�.:�,�:.;-111�:' Licensa low for�ihe following reason.(Seclion 7031.5, � � .1,.` . ' ,_- .�...._..__.___.,___ _'"'' . :.. .�_..�......_.,_' . � BQsune�s3OondPro/eulonzCodeJ:Anycilyorco�qlywhltb . _ v . �. .��. �\_ �T�1 ��.� �.�� �. .1 . � .. . . - � q "perml�lo mnsf uc/ aher,imp'ove,ilemolish, ` [�or repolr any struc�ore, prlor��o fts.issoance, also rc� � � ,��,�_�__._ �. __.��.: , ,�l _ .e - _,i . � .� `.�\�quftesJhe app(icdnt!or such perrrilflo 1Je a sfgned state� . � . i f i - • ' • - '"� ; �' mvnt}Fa/he! OcensedpursuaN to,lhe proNsions of Jhe � ' ..�� t�\�_�1\__, •�! � . � ��' ( ...�. •�. , Confrocfo'r.'i-Llcanae�Law Chapter 9�(commencing wtlh ' 1 .�.�..._._ !�1...t _:.�Ar __."' �� _ , � ..r�I ` �Set�lon 7000J o1 P ision 3 oI fhe.Business and P,rolos- I� � ��� � '� I:�_� ; i '-_-___._. .___._ ':• 7�. ':. �'.'.-�,.! � , �/o�n�he�.ofle ed�e ems�f`onmAnhevrolamcndlhebasls . \ � ' . . �.�. __...__I;�� i !'__._...__ _ '_- ___ __ ..._ ,. . � ��.:7031.5 by�on9 opyi'canPlor o pe mlt sub�ects + Sectlon -- �---- - - -- Y _ �the�oppfi- . ,,.. . � . ,. i_ � :�.i ��,can�to.a civll.ponblty ol not�more',than,llve hundred �" -�`' . .. - -�---� --�- �— �, do (E500).: . .. . .. . _ i � � "�' � i I --_--- .--.-- -.--.--."' '' �. "�:�� �❑I,os owner of Ihe ropert will do the work,i nd �_ _'.___ . .'_ '_. ._. ____ . __ ' _ . ._ . . " . Y ,., I �-, ,;.'.• ' I ; . ,.,.. . ., ..,, - the�t uUure is� t n�ended�or,offered for saie ' � � . . .... . . ., .� ; � ..... . „ . . _ �- -----� �- �--- - -- ���-- - --- -- �---�. � - � � �.:(Sec.7044,Business andProfesslons Code: TheConlrac- " '`,`: � ,. ,. .;. .� i �` .t.ior f Gcense Law�does nolopp7y fo an owner oiproperty � :. �. ..� , .. ... .., . . . . . . -� � "---� i ___' i �; ..who�bVtlds or�fmprovas lhoreon, ond;who�daes.such - 1. � � r I _. __ � „ . ,.. work blmsel/provided fhof suth Improvemenfs ore no� � �S� '�._.)\j, .�� � ^�� �\ - Inlended or o(fered for_sale,H,-however;.fhc buflding or �� . . � �. _.., . . .- ; ,-.. � ,7mprovement 7s so�d wilhln ana.yaano/romplelfan,1he ' '. �---� �---� '��� ' -•-�:�:owner•bullderwtllhava the 6urden oiproving fFat he did ,,. . � . .__ . .___.-_ _____ � _... � . � ,. 1 \-`.i . . � �i�.. ; . -. -..'nol 6u11d or Improve/or 1be purp�e ol sala.f.`.. .. , � . ' � I �'., _.:i. . � .. , . , . .. .. . . _ -- ._.._. ._.. ��.-' . , _. _1�y -! . i � _;.j0 I,.as owner of,the proper .am.ezclusively com �. :�� � � I � I � ° � � �-- -�trocting wifh licented cantroctors�o-construct tAe'project ;.. :�.__ i_. _�. �� . .. � ---I-.. I ..'--- -- ...-- ' '-� - -� (Scc.704a)Busines's.and Pr���lons{ode.ihe PC�o�rar \ � r{-.�a r..' � i �-�foraLlcensoYawdoesriotp I��}oonownerof rq erfy • �- � - who bullds or Improves,fh ond who Fen! c s/or : ,'.� , o e . ',F . ��`"�� '-��'i � such projecfs wlth a controctor(sJ I�censed pursuant fo _ 1-._._- ���----_..___. .. ..__--- �-- ' . ---' .._, �%. . . ,..._.. ,.. . ... _.. ...._ . �-..--1ho CoMraclor's�Ucrose CawJ.'=' - '' � .„ . , �-:,. •,.. •-- � -� . , A � • ..j� ... .- _._�_:.�--. . . . , - , �-__._.--_..-�--_. .. --�---._ .. _-_. __._-.. . , _�r� ����f- ��- _ - ----- ...- . "_ --._. _--.''_'..-'__--- __...-- --� .___ .__ , . r�_,. ,- . . . . _ i ._ .___ _ . .._.._ �: _�.: ' ' ' ` ` . � ' ' �'� I am exempt undor Sec. i;,— � ;�) ! .. - , ,:, _ , _. �, i ., . - �B&P.C.for this rcason � � . 1 � . _ . .. , . ' .. �. � , - . � , . . ..,. ., ,.. - � . , . .} � .,., ._.,, ` , . ... � . ,...., ,:. . .. ... ....:... . . . �� - _l''« �� V. .,\i�:_S; �,.� � Date _ ,. _ . . �. � , . . __ . . , _ .._ , . , ....., , " `�.,.\ � .: . •-��5,r.q� �1 � Owner — _ - _ A t _U •7', �1_ a�. � -_ . • . • .. , � ��. f . `-"J \ ". L. ` ._d.�-•.�(ui. . ..3 ... . ... . .. . .. .. ,... j .. , INSPECTOR'S NOTES ----- -_ _ _ _ � � , , , � , ,�-1 . ,_�:_�. �.�,� , .� �_ : _--- _ - -' ' - --� --—--__._ �:�: _ - � --- -- ___ _ _ .. . � . v . _-' • - ' - ----. __. i .- - - - - -- _.--�---- -_ __ -• : .- -•. _ . \�>>>\ �(� . �., i, ,,.. � � ,. ., .� .. : .. . � �, � , f,... ,, . . . . . �. ';�. , , . . ,.�.1 . . .. , .. "' . ` f� .��}� �1�" __— �� .�_ � . ,-..— ��.-1 f�i . . .. . � . �J • . . . .. , • . ,, 1